88501-2
MEDICATIONS
Active
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.
Source: Regenstrief LOINC
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
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- 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 LL4499-1
Answer | Code | Score | Answer ID |
---|---|---|---|
No - No issues found during review | 0 | LA27634-7 | |
Yes - Issues found during review | 1 | LA27635-4 | |
NA - Resident is not taking any medications | 9 | LA27636-2 |
Member of these Panels
LOINC | Long Common Name |
---|---|
103991-6 | CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment] |
88954-3 | Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment] |
88949-3 | Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment] |
88955-0 | Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment] |
88950-1 | Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment] |
57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
89963-3 | Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment] |
93128-7 | Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment] |
87509-6 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment] |
93222-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment] |
103949-4 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment] |
90473-0 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
90474-8 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
90475-5 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
90476-3 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
101105-5 | MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
101110-5 | MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
101106-3 | MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
101112-1 | MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
103564-1 | MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
104552-5 | MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
104554-1 | MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
104609-3 | MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
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
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- 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
Answer | Code | Score | Answer ID |
---|---|---|---|
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
LOINC | Long Common Name |
---|---|
103991-6 | CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment] |
88954-3 | Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment] |
88949-3 | Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment] |
88955-0 | Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment] |
88950-1 | Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment] |
57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
89963-3 | Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment] |
93128-7 | Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment] |
87509-6 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment] |
93222-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment] |
103949-4 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment] |
90473-0 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
90474-8 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
90475-5 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
90476-3 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
101105-5 | MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
101110-5 | MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
101106-3 | MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
101112-1 | MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
103564-1 | MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
104552-5 | MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
104554-1 | MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
104609-3 | MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
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
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- 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
Answer | Code | Score | Answer ID |
---|---|---|---|
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications | NA | LA12317-6 |
Member of these Panels
LOINC | Long Common Name |
---|---|
57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
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 ServicesFully-Specified Name
- Component
- Management of oral medications - ability
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- 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
Answer | Code | Score | Answer ID |
---|---|---|---|
Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times. | 0 | LA6135-3 | |
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. | 1 | LA12322-6 | |
Able to take medication(s) at the correct times if given reminders by another person at the appropriate times | 2 | LA12323-4 | |
Unable to take medication unless administered by another person. | 3 | LA12324-2 | |
No oral medications prescribed. | NA | LA6290-6 |
Member of these Panels
LOINC | Long Common Name |
---|---|
57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
86264-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] |
86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
88371-0 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment] |
88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
99178-6 | Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment] |
99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
99131-5 | Outcome and assessment information set (OASIS) form - version E - 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 ServicesFully-Specified Name
- Component
- Management of injectable medications - ability
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- 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
Answer | Code | Score | Answer ID |
---|---|---|---|
Able to independently take the correct medication(s) and proper dosage(s) at the correct times. | 0 | LA12326-7 | |
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. | 1 | LA12327-5 | |
Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection | 2 | LA12328-3 | |
Unable to take injectable medication unless administered by another person. | 3 | LA12329-1 | |
No injectable medications prescribed. | NA | LA6280-7 |
Member of these Panels
LOINC | Long Common Name |
---|---|
57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
86264-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] |
86244-1 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] |
86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
88369-4 | Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
93058-6 | Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |