57255-2 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?

Term Description

Indicates whether a drug regimen review indicate potential clinically significant medication issues.

Observation ID in Form

M2001

Skip Logic

If 0, go to M2010. If NA, go to M2102.

Fully-Specified Name

Component
Drug regimen review identified potential medication issues
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Drug regimen review identified potential medication issues during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.77 (MAJ)
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Expanded Component to be more precise
Order vs. Observation
Observation

Normative Answer List LL5418-0

AnswerCodeScoreAnswer ID
No - No issues found during review0LA27634-7
Yes - Issues found during review1LA27635-4
Not applicable - Patient is not taking any medications9LA30361-2

Member of these Panels

LOINCLong Common Name
103991-6CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
88954-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88949-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
57039-0Deprecated Outcome and assessment information set (OASIS) form - version C
57191-9Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
86189-8Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
113114-3Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103564-1MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104552-5MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104609-3MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
106525-9Outcome and assessment information set (OASIS) form - version E1 - Resumption of Care during assessment period [CMS Assessment]
106523-4Outcome and assessment information set (OASIS) form - version E1 - Start of Care during assessment period [CMS Assessment]
108292-4Outcome and assessment information set (OASIS) form - version E2 - Resumption of Care during assessment period [CMS Assessment]
108291-6Outcome and assessment information set (OASIS) form - version E2 - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

57281-8 Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?

Observation ID in Form

M2003

Fully-Specified Name

Component
Medication follow-up
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Medication follow-up during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.77 (MAJ)
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms
Order vs. Observation
Observation

Normative Answer List LL251-0

AnswerCodeScoreAnswer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)0LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)1LA33-6

Member of these Panels

LOINCLong Common Name
103991-6CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
88954-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88949-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
57039-0Deprecated Outcome and assessment information set (OASIS) form - version C
57191-9Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
86189-8Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
113114-3Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103564-1MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104552-5MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104609-3MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
106525-9Outcome and assessment information set (OASIS) form - version E1 - Resumption of Care during assessment period [CMS Assessment]
106523-4Outcome and assessment information set (OASIS) form - version E1 - Start of Care during assessment period [CMS Assessment]
108292-4Outcome and assessment information set (OASIS) form - version E2 - Resumption of Care during assessment period [CMS Assessment]
108291-6Outcome and assessment information set (OASIS) form - version E2 - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

57257-8 Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?

Observation ID in Form

M2010

Fully-Specified Name

Component
Patient &or caregiver received high risk drug education
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Patient/caregiver received high risk drug education during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.77 (MAJ)
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Added "received" to Component for clarity
Order vs. Observation
Observation

Normative Answer List LL816-0

AnswerCodeScoreAnswer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)0LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)1LA33-6
Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medicationsNALA12317-6

Member of these Panels

LOINCLong Common Name
57039-0Deprecated Outcome and assessment information set (OASIS) form - version C
57191-9Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
86189-8Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
106525-9Outcome and assessment information set (OASIS) form - version E1 - Resumption of Care during assessment period [CMS Assessment]
106523-4Outcome and assessment information set (OASIS) form - version E1 - Start of Care during assessment period [CMS Assessment]
108292-4Outcome and assessment information set (OASIS) form - version E2 - Resumption of Care during assessment period [CMS Assessment]
108291-6Outcome and assessment information set (OASIS) form - version E2 - Start of Care during assessment period [CMS Assessment]

57285-9 Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Observation ID in Form

M2020

Form Coding Instructions

Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Management of oral medications - ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Management of oral medications - ability during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.77 (MAJ)
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Edited Component to match LOINC conventions
Order vs. Observation
Observation

Normative Answer List LL818-6

AnswerCodeScoreAnswer ID
Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.0LA6135-3
Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.1LA12322-6
Able to take medication(s) at the correct times if given reminders by another person at the appropriate times2LA12323-4
Unable to take medication unless administered by another person.3LA12324-2
No oral medications prescribed.NALA6290-6

Member of these Panels

LOINCLong Common Name
57039-0Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57191-9Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
86264-9Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
86189-8Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
108293-2OASIS E2 - DC during assessment period [CMS Assessment]
88371-0Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
106529-1Outcome and assessment information set (OASIS) form - version E1 - Discharge from Agency during assessment period [CMS Assessment]
106525-9Outcome and assessment information set (OASIS) form - version E1 - Resumption of Care during assessment period [CMS Assessment]
106523-4Outcome and assessment information set (OASIS) form - version E1 - Start of Care during assessment period [CMS Assessment]
108292-4Outcome and assessment information set (OASIS) form - version E2 - Resumption of Care during assessment period [CMS Assessment]
108291-6Outcome and assessment information set (OASIS) form - version E2 - Start of Care during assessment period [CMS Assessment]

57284-2 Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals

Observation ID in Form

M2030

Form Coding Instructions

Excludes IV medications

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Management of injectable medications - ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Management of injectable medications - ability during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.77 (MAJ)
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Edited Component to match LOINC conventions
Order vs. Observation
Observation

Normative Answer List LL819-4

AnswerCodeScoreAnswer ID
Able to independently take the correct medication(s) and proper dosage(s) at the correct times.0LA12326-7
Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.1LA12327-5
Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection2LA12328-3
Unable to take injectable medication unless administered by another person.3LA12329-1
No injectable medications prescribed.NALA6280-7

Member of these Panels

LOINCLong Common Name
57039-0Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57192-7Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up
57191-9Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
86264-9Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
86244-1Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
86189-8Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
88369-4Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
106525-9Outcome and assessment information set (OASIS) form - version E1 - Resumption of Care during assessment period [CMS Assessment]
106523-4Outcome and assessment information set (OASIS) form - version E1 - Start of Care during assessment period [CMS Assessment]
108292-4Outcome and assessment information set (OASIS) form - version E2 - Resumption of Care during assessment period [CMS Assessment]
108291-6Outcome and assessment information set (OASIS) form - version E2 - Start of Care during assessment period [CMS Assessment]