88955-0
Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
Deprecated
Status Information
- Status
- DEPRECATED
Term Description
This panel should be used for CMS MDS3.0 v1.16.1 NQ assessments performed between October 1, 2018 and September 30, 2019.
Source: Regenstrief LOINC
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 88955-0 | Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment] | |||
| Indent86809-1 | Identification Information | |||
| Indent Indent58198-3 | Type of Record | |||
| Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent85632-8 | Type of Provider | |||
| Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent54585-5 | PPS Other Medicare Required Assessment - OMRA | |||
| Indent Indent Indent58107-4 | Is this a Swing Bed clinical change assessment? | |||
| Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent45397-7 | Medicare number (or comparable railroad insurance number) | |||
| Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent46098-0 | Gender | |||
| Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent59362-4 | Race/Ethnicity | 1..6 | ||
| Indent Indent54505-3 | Language | |||
| Indent Indent Indent54588-9 | Does the resident need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent54899-0 | Preferred language | |||
| Indent Indent45404-1 | Marital Status | |||
| Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent52455-3 | Admission Date (Date this episode of care in this facility began) | {mm/dd/yyyy} | ||
| Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent55128-3 | Discharge Status | |||
| Indent Indent54592-1 | Previous Assessment Reference Date for Significant Correction | {mm/dd/yyyy} | ||
| Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent54508-7 | Hearing, Speech, and Vision | |||
| Indent Indent54597-0 | Comatose. Persistent vegetative state/no discernible consciousness | |||
| Indent Indent54598-8 | Hearing. Ability to hear (with hearing aid or hearing appliances if normally used) | |||
| Indent Indent54599-6 | Hearing Aid. Hearing aid or other hearing appliance used in completing B0200, Hearing | |||
| Indent Indent54600-2 | Speech Clarity. Select best description of speech pattern | |||
| Indent Indent54601-0 | Makes Self Understood. Ability to express ideas and wants, consider both verbal and non-verbal expression | |||
| Indent Indent54602-8 | Ability to Understand Others. Understanding verbal content, however able (with hearing aid or device if used) | |||
| Indent Indent54603-6 | Vision. Ability to see in adequate light (with glasses or other visual appliances) | |||
| Indent Indent54604-4 | Corrective Lenses. Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision | |||
| Indent86529-5 | Cognitive Patterns | |||
| Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent52491-8 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent52731-7 | Repetition of Three Words. Number of words repeated after first attempt | |||
| Indent Indent Indent54510-3 | Temporal Orientation (orientation to year, month, and day) | |||
| Indent Indent Indent Indent52732-5 | Able to report correct year | |||
| Indent Indent Indent Indent52733-3 | Able to report correct month | |||
| Indent Indent Indent Indent54609-3 | Able to report correct day of the week | |||
| Indent Indent Indent52493-4 | Recall | |||
| Indent Indent Indent Indent52735-8 | Able to recall "sock" | |||
| Indent Indent Indent Indent52736-6 | Able to recall "blue" | |||
| Indent Indent Indent Indent52737-4 | Able to recall "bed" | |||
| Indent Indent Indent54614-3 | BIMS Summary Score | {score} | ||
| Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted? | |||
| Indent Indent86595-6 | Staff Assessment for Mental Status | |||
| Indent Indent Indent54616-8 | Short-term Memory OK. Seems or appears to recall after 5 minutes | |||
| Indent Indent Indent54617-6 | Long-term Memory OK. Seems or appears to recall long past | |||
| Indent Indent Indent86583-2 | Memory/Recall Ability | 1..4 | ||
| Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making. Made decisions regarding tasks of daily life | |||
| Indent Indent86584-0 | Delirium | |||
| Indent Indent Indent86585-7 | Signs and Symptoms of Delirium (from CAM) | |||
| Indent Indent Indent Indent54632-5 | Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the resident's baseline? | |||
| Indent Indent Indent Indent54628-3 | Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? | |||
| Indent Indent Indent Indent54629-1 | Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? | |||
| Indent Indent Indent Indent54630-9 | Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by any of the following criteria? | |||
| Indent54633-3 | Mood | |||
| Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent54635-8 | Resident Mood Interview (PHQ-9) | |||
| Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54650-7 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54651-5 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent54654-9 | Total Severity Score | {score} | ||
| Indent Indent54655-6 | Safety Notification. Was responsible staff or provider informed that there is a potential for resident self harm? | |||
| Indent Indent54657-2 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54668-9 | Indicating that s/he feels bad about self, is a failure, or has let self or family down | |||
| Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual | |||
| Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54669-7 | Indicating that s/he feels bad about self, is a failure, or has let self or family down | |||
| Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual | |||
| Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent54677-0 | Total Severity Score | {score} | ||
| Indent Indent54655-6 | Safety Notification. Was responsible staff or provider informed that there is a potential for resident self harm? | |||
| Indent86815-8 | Behavior | |||
| Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent54692-9 | Rejection of Care - Presence & Frequency. Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? | d/(7.d) | ||
| Indent Indent54693-7 | Wandering - Presence & Frequency. Has the resident wandered? | d/(7.d) | ||
| Indent86816-6 | Functional status | |||
| Indent Indent86880-2 | Activities of Daily Living (ADL) Assistance. Self-Performance | |||
| Indent Indent Indent45588-1 | Bed mobility | |||
| Indent Indent Indent45590-7 | Transfer | |||
| Indent Indent Indent45592-3 | Walk in room | |||
| Indent Indent Indent45594-9 | Walk in corridor | |||
| Indent Indent Indent45596-4 | Locomotion on unit | |||
| Indent Indent Indent45598-0 | Locomotion off unit | |||
| Indent Indent Indent45600-4 | Dressing | |||
| Indent Indent Indent45602-0 | Eating | |||
| Indent Indent Indent45604-6 | Toilet use | |||
| Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent86881-0 | Activities of Daily Living (ADL) Assistance. Support Provided | |||
| Indent Indent Indent45589-9 | Bed mobility | |||
| Indent Indent Indent45591-5 | Transfer | |||
| Indent Indent Indent45593-1 | Walk in room | |||
| Indent Indent Indent45595-6 | Walk in corridor | |||
| Indent Indent Indent45597-2 | Locomotion on unit | |||
| Indent Indent Indent45599-8 | Locomotion off unit | |||
| Indent Indent Indent45601-2 | Dressing | |||
| Indent Indent Indent45603-8 | Eating | |||
| Indent Indent Indent45605-3 | Toilet use | |||
| Indent Indent Indent45607-9 | Personal hygiene | |||
| Indent Indent46008-9 | Bathing | |||
| Indent Indent Indent45608-7 | Self-performance | |||
| Indent Indent Indent45609-5 | Support provided | |||
| Indent Indent54524-4 | Balance During Transitions and Walking | |||
| Indent Indent Indent54749-7 | Moving from seated to standing position | |||
| Indent Indent Indent54750-5 | Walking (with assistive device if used) | |||
| Indent Indent Indent54751-3 | Turning around and facing the opposite direction while walking | |||
| Indent Indent Indent54752-1 | Moving on and off toilet | |||
| Indent Indent Indent54753-9 | Surface-to-surface transfer (transfer between bed and chair or wheelchair) | |||
| Indent Indent92908-3 | Functional Limitation in Range of Motion | |||
| Indent Indent Indent92850-7 | Upper extremity (shoulder, elbow, wrist, hand) | |||
| Indent Indent Indent92851-5 | Lower extremity (hip, knee, ankle, foot) | |||
| Indent Indent86602-0 | Mobility Devices | 1..4 | ||
| Indent88482-5 | Functional Abilities and Goals - Admission (Start of SNF PPS Stay) | |||
| Indent Indent83239-4 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent83233-7 | Self-Care - Admission Performance | |||
| Indent Indent Indent83232-9 | Eating | |||
| Indent Indent Indent83230-3 | Oral hygiene | |||
| Indent Indent Indent83228-7 | Toileting hygiene | |||
| Indent Indent Indent83226-1 | Shower/bathe self | |||
| Indent Indent Indent83224-6 | Upper body dressing | |||
| Indent Indent Indent83222-0 | Lower body dressing | |||
| Indent Indent Indent83220-4 | Putting on/taking off footwear | |||
| Indent Indent85054-5 | Self-Care - Discharge Goal | |||
| Indent Indent Indent83231-1 | Eating | |||
| Indent Indent Indent83229-5 | Oral hygiene | |||
| Indent Indent Indent83227-9 | Toileting hygiene | |||
| Indent Indent Indent83225-3 | Shower/bathe self | |||
| Indent Indent Indent83223-8 | Upper body dressing | |||
| Indent Indent Indent83221-2 | Lower body dressing | |||
| Indent Indent Indent83219-6 | Putting on/taking off footwear | |||
| Indent Indent88330-6 | Mobility - Admission Performance | |||
| Indent Indent Indent83218-8 | Roll left and right | |||
| Indent Indent Indent83216-2 | Sit to lying | |||
| Indent Indent Indent83214-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent83212-1 | Sit to stand | |||
| Indent Indent Indent83210-5 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent83208-9 | Toilet transfer | |||
| Indent Indent Indent83206-3 | Car transfer | |||
| Indent Indent Indent83204-8 | Walk 10 feet | |||
| Indent Indent Indent83202-2 | Walk 50 feet with two turns | |||
| Indent Indent Indent83200-6 | Walk 150 feet | |||
| Indent Indent Indent83198-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent83196-6 | 1 step (curb) | |||
| Indent Indent Indent83194-1 | 4 steps | |||
| Indent Indent Indent83192-5 | 12 steps | |||
| Indent Indent Indent83190-9 | Picking up object | |||
| Indent Indent Indent83271-7 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent83188-3 | Wheel 50 feet with two turns | |||
| Indent Indent Indent83272-5 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent83235-2 | Wheel 150 feet | |||
| Indent Indent Indent83272-5 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent85056-0 | Mobility - Discharge Goal | |||
| Indent Indent Indent83217-0 | Roll left and right | |||
| Indent Indent Indent83215-4 | Sit to lying | |||
| Indent Indent Indent83213-9 | Lying to sitting on side of bed | |||
| Indent Indent Indent83211-3 | Sit to stand | |||
| Indent Indent Indent83209-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent83207-1 | Toilet transfer | |||
| Indent Indent Indent83205-5 | Car transfer | |||
| Indent Indent Indent83203-0 | Walk 10 feet | |||
| Indent Indent Indent83201-4 | Walk 50 feet with two turns | |||
| Indent Indent Indent83199-0 | Walk 150 feet | |||
| Indent Indent Indent83197-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent83195-8 | 1 step (curb) | |||
| Indent Indent Indent83193-3 | 4 steps | |||
| Indent Indent Indent83191-7 | 12 steps | |||
| Indent Indent Indent83189-1 | Picking up object | |||
| Indent Indent Indent83187-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent83236-0 | Wheel 150 feet | |||
| Indent88483-3 | Functional Abilities and Goals - Discharge (End of SNF PPS Stay) | |||
| Indent Indent83254-3 | Self-Care - Discharge Performance | |||
| Indent Indent Indent83232-9 | Eating | |||
| Indent Indent Indent83230-3 | Oral hygiene | |||
| Indent Indent Indent83228-7 | Toileting hygiene | |||
| Indent Indent Indent83226-1 | Shower/bathe self | |||
| Indent Indent Indent83224-6 | Upper body dressing | |||
| Indent Indent Indent83222-0 | Lower body dressing | |||
| Indent Indent Indent83220-4 | Putting on/taking off footwear | |||
| Indent Indent88331-4 | Mobility - Discharge Performance | |||
| Indent Indent Indent83218-8 | Roll left and right | |||
| Indent Indent Indent83216-2 | Sit to lying | |||
| Indent Indent Indent83214-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent83212-1 | Sit to stand | |||
| Indent Indent Indent83210-5 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent83208-9 | Toilet transfer | |||
| Indent Indent Indent83206-3 | Car transfer | |||
| Indent Indent Indent83204-8 | Walk 10 feet | |||
| Indent Indent Indent83202-2 | Walk 50 feet with two turns | |||
| Indent Indent Indent83200-6 | Walk 150 feet | |||
| Indent Indent Indent83198-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent83196-6 | 1 step (curb) | |||
| Indent Indent Indent83194-1 | 4 steps | |||
| Indent Indent Indent83192-5 | 12 steps | |||
| Indent Indent Indent83190-9 | Picking up object | |||
| Indent Indent Indent83271-7 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent83188-3 | Wheel 50 feet with two turns | |||
| Indent Indent Indent83272-5 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent83235-2 | Wheel 150 feet | |||
| Indent Indent Indent83272-5 | Indicate the type of wheelchair or scooter used | |||
| Indent89049-1 | Bladder and Bowel | |||
| Indent Indent86624-4 | Appliances | 1..4 | ||
| Indent Indent86866-1 | Urinary Toileting Program | |||
| Indent Indent Indent54767-9 | Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? | |||
| Indent Indent Indent54769-5 | Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence? | |||
| Indent Indent54770-3 | Urinary Continence | 1..1 | ||
| Indent Indent54771-1 | Bowel Continence | 1..1 | ||
| Indent Indent88695-2 | Bowel Toileting Program. Is a toileting program currently being used to manage the resident's bowel continence? | |||
| Indent88957-6 | Active diagnoses | |||
| Indent Indent96095-5 | Indicate the resident's primary medical condition category | 1..1 | ||
| Indent Indent52797-8 | Other medical condition | |||
| Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent88959-2 | Health Conditions | |||
| Indent Indent54557-4 | Pain Management | |||
| Indent Indent Indent71447-7 | At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? | |||
| Indent Indent Indent71448-5 | At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined? | |||
| Indent Indent Indent71449-3 | At any time in the last 5 days, has the resident: Received non-medication intervention for pain? | |||
| Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent54558-2 | Pain Assessment Interview | |||
| Indent Indent Indent54829-7 | Pain Presence. Have you had pain or hurting at any time in the last 5 days? | |||
| Indent Indent Indent54830-5 | Pain Frequency. How much of the time have you experienced pain or hurting over the last 5 days? | |||
| Indent Indent Indent54559-0 | Pain Effect on Function | |||
| Indent Indent Indent Indent54831-3 | Over the past 5 days, has pain made it hard for you to sleep at night? | |||
| Indent Indent Indent Indent54832-1 | Over the past 5 days, have you limited your day-to-day activities because of pain? | |||
| Indent Indent Indent54560-8 | Pain Intensity | |||
| Indent Indent Indent Indent54833-9 | Numeric Rating Scale (00-10) | |||
| Indent Indent Indent Indent54834-7 | Verbal Descriptor Scale | |||
| Indent Indent58117-3 | Should the Staff Assessment for Pain be Conducted? | |||
| Indent Indent86672-3 | Staff Assessment for Pain | |||
| Indent Indent Indent86673-1 | Indicators of Pain or Possible Pain in the last 5 days | 1..4 | ||
| Indent Indent Indent58118-1 | Frequency of Indicator of Pain or Possible Pain in the last 5 days. Frequency with which resident complains or shows evidence of pain or possible pain | d/(5.d) | ||
| Indent Indent86868-7 | Other Health Conditions | |||
| Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..3 | ||
| Indent Indent Indent54846-1 | Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? | |||
| Indent Indent Indent86676-4 | Problem Conditions | 1..4 | ||
| Indent Indent Indent54849-5 | Fall History on Admission/Entry or Reentry | |||
| Indent Indent Indent Indent54850-3 | Did the resident have a fall any time in the last month prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent54851-1 | Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent54852-9 | Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent54853-7 | Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? | |||
| Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent83274-1 | Prior Surgery. Did the resident have major surgery during the 100 days prior to admission? | |||
| Indent86625-1 | Swallowing/Nutritional Status | |||
| Indent Indent86677-2 | Swallowing Disorder. Signs and symptoms of possible swallowing disorder | 1..4 | ||
| Indent Indent54567-3 | Height and Weight | |||
| Indent Indent Indent3137-7 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent3141-9 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent54863-6 | Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in last 6 months | |||
| Indent Indent86678-0 | Weight Gain. Gain of 5% or more in the last month or gain of 10% or more in last 6 months | |||
| Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..4 | ||
| Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..4 | ||
| Indent Indent86679-8 | Percent Intake by Artificial Route | |||
| Indent Indent Indent86680-6 | Proportion of total calories the resident received through parenteral or tube feeding. While NOT a Resident | |||
| Indent Indent Indent86681-4 | Proportion of total calories the resident received through parenteral or tube feeding. While a Resident | |||
| Indent Indent Indent86687-1 | Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days | |||
| Indent Indent Indent86682-2 | Average fluid intake per day by IV or tube feeding. While NOT a Resident | mL/d;L/d | ||
| Indent Indent Indent86683-0 | Average fluid intake per day by IV or tube feeding. While a Resident | mL/d;L/d | ||
| Indent Indent Indent86684-8 | Average fluid intake per day by IV or tube feeding. During Entire 7 Days | mL/d;L/d | ||
| Indent86685-5 | Oral/Dental Status | |||
| Indent Indent86706-9 | Dental | 1..2 | ||
| Indent88960-0 | Skin Conditions | |||
| Indent Indent86708-5 | Determination of Pressure Ulcer/Injury Risk | 1..3 | ||
| Indent Indent57280-0 | Risk of Pressure Ulcers/Injuries. Is this resident at risk of developing pressure ulcers/injuries? | |||
| Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries? | |||
| Indent Indent88961-8 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent54884-2 | Number of Stage 1 pressure injuries | {#} | ||
| Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent54970-9 | Number of Venous and Arterial Ulcers | {#} | ||
| Indent Indent88696-0 | Other Ulcers, Wounds and Skin Problems | 1..8 | ||
| Indent Indent86748-1 | Skin and Ulcer/Injury Treatments | 1..9 | ||
| Indent88962-6 | Medications | |||
| Indent Indent54982-4 | Injections. Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. | d/(7.d) | ||
| Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent58127-2 | Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days | d/(7.d) | ||
| Indent Indent Indent58128-0 | Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days | d/(7.d) | ||
| Indent Indent88290-2 | Medications Received | |||
| Indent Indent Indent86751-5 | Antipsychotic | d/(7.d) | ||
| Indent Indent Indent86752-3 | Antianxiety | d/(7.d) | ||
| Indent Indent Indent86753-1 | Antidepressant | d/(7.d) | ||
| Indent Indent Indent86754-9 | Hypnotic | d/(7.d) | ||
| Indent Indent Indent86755-6 | Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin) | d/(7.d) | ||
| Indent Indent Indent86756-4 | Antibiotic | d/(7.d) | ||
| Indent Indent Indent86757-2 | Diuretic | d/(7.d) | ||
| Indent Indent Indent88291-0 | Opiod | d/(7.d) | ||
| Indent Indent88295-1 | Antipsychotic Medication Review | |||
| Indent Indent Indent88296-9 | Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? | |||
| Indent Indent Indent88297-7 | Has a gradual dose reduction (GDR) been attempted? | |||
| Indent Indent Indent88298-5 | Date of last attempted GDR | {mm/dd/yyyy} | ||
| Indent Indent Indent88299-3 | Physician documented GDR as clinically contraindicated | |||
| Indent Indent Indent88300-9 | Date physician documented GDR as clinically contraindicated | {mm/dd/yyyy} | ||
| Indent Indent57255-2 | Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? | |||
| Indent Indent57281-8 | Medication Follow-up: Did the facility 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? | |||
| Indent Indent57256-0 | Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the admission? | |||
| Indent86834-9 | Special treatments, procedures, and programs | |||
| Indent Indent86759-8 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent86760-6 | While NOT a Resident | 0..9 | ||
| Indent Indent Indent86761-4 | While a Resident | 0..11 | ||
| Indent Indent69339-0 | Influenza Vaccine | |||
| Indent Indent Indent55019-4 | Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? | |||
| Indent Indent Indent58131-4 | Date influenza vaccine received | {mm/dd/yyyy} | ||
| Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent55021-0 | Pneumococcal Vaccine | |||
| Indent Indent Indent55022-8 | Is the resident's Pneumococcal vaccination up to date? | |||
| Indent Indent Indent45956-0 | If Pneumococcal vaccine not received, state reason: | |||
| Indent Indent86841-4 | Therapies | |||
| Indent Indent Indent86763-0 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent58218-9 | Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days | min | ||
| Indent Indent Indent Indent58133-0 | Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days | min | ||
| Indent Indent Indent Indent58134-8 | Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days | min | ||
| Indent Indent Indent Indent86765-5 | Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days | min | ||
| Indent Indent Indent Indent45760-6 | Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days | d/(7.d) | ||
| Indent Indent Indent Indent55025-1 | Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55026-9 | Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended | {mm/dd/yyyy} | ||
| Indent Indent Indent86767-1 | Occupational Therapy | |||
| Indent Indent Indent Indent58219-7 | Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days | min | ||
| Indent Indent Indent Indent58136-3 | Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days | min | ||
| Indent Indent Indent Indent58137-1 | Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days | min | ||
| Indent Indent Indent Indent86764-8 | Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days | min | ||
| Indent Indent Indent Indent45762-2 | Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days | d/(7.d) | ||
| Indent Indent Indent Indent55027-7 | Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55028-5 | Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended | {mm/dd/yyyy} | ||
| Indent Indent Indent86768-9 | Physical Therapy | |||
| Indent Indent Indent Indent58220-5 | Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days | min | ||
| Indent Indent Indent Indent58139-7 | Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days | min | ||
| Indent Indent Indent Indent58140-5 | Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days | min | ||
| Indent Indent Indent Indent86766-3 | Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days | min | ||
| Indent Indent Indent Indent45764-8 | Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days | d/(7.d) | ||
| Indent Indent Indent Indent55029-3 | Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55030-1 | Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended | {mm/dd/yyyy} | ||
| Indent Indent Indent86849-7 | Respiratory therapy | |||
| Indent Indent Indent Indent45766-3 | Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days | d/(7.d) | ||
| Indent Indent Indent86850-5 | Psychological therapy | |||
| Indent Indent Indent Indent45768-9 | Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days. | d/(7.d) | ||
| Indent Indent86769-7 | Distinct Calendar Days of Therapy. Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days. | d | ||
| Indent Indent86770-5 | Resumption of Therapy | |||
| Indent Indent Indent86772-1 | Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline? | |||
| Indent Indent Indent86771-3 | Date on which therapy regimen resumed | {mm/dd/yyyy} | ||
| Indent Indent86773-9 | Restorative Nursing Programs | |||
| Indent Indent Indent86774-7 | Technique. Range of motion (passive) | d/(7.d) | ||
| Indent Indent Indent86775-4 | Technique. Range of motion (active) | d/(7.d) | ||
| Indent Indent Indent86776-2 | Technique. Splint or brace assistance | d/(7.d) | ||
| Indent Indent Indent86777-0 | Training and Skill Practice In: Bed mobility | d/(7.d) | ||
| Indent Indent Indent86778-8 | Training and Skill Practice In: Transfer | d/(7.d) | ||
| Indent Indent Indent86779-6 | Training and Skill Practice In: Walking | d/(7.d) | ||
| Indent Indent Indent86780-4 | Training and Skill Practice In: Dressing and/or grooming | d/(7.d) | ||
| Indent Indent Indent86781-2 | Training and Skill Practice In: Eating and/or swallowing | d/(7.d) | ||
| Indent Indent Indent86782-0 | Training and Skill Practice In: Amputation/prostheses care | d/(7.d) | ||
| Indent Indent Indent86783-8 | Training and Skill Practice In: Communication | d/(7.d) | ||
| Indent Indent55040-0 | Physician Examinations. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident? | d/(14.d) | ||
| Indent Indent55041-8 | Physician Orders. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders? | d/(14.d) | ||
| Indent88307-4 | Restraints and Alarms | |||
| Indent Indent86785-3 | Physical Restraints | |||
| Indent Indent Indent86786-1 | Used in Bed. Bed rail | d/(7.d) | ||
| Indent Indent Indent86787-9 | Used in Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent86788-7 | Used in Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent86789-5 | Used in Bed. Other | d/(7.d) | ||
| Indent Indent Indent86790-3 | Used in Chair or Out of Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent86791-1 | Used in Chair or Out of Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent86792-9 | Used in Chair or Out of Bed. Chair prevents rising | d/(7.d) | ||
| Indent Indent Indent86793-7 | Used in Chair or Out of Bed. Other | d/(7.d) | ||
| Indent Indent88309-0 | Alarms | |||
| Indent Indent Indent88310-8 | Bed alarm | |||
| Indent Indent Indent88311-6 | Chair alarm | |||
| Indent Indent Indent88312-4 | Floor mat alarm | |||
| Indent Indent Indent88313-2 | Motion sensor alarm | |||
| Indent Indent Indent88314-0 | Wander/elopement alarm | |||
| Indent Indent Indent88308-2 | Other alarm | |||
| Indent86794-5 | Participation in Assessment and Goal Setting | |||
| Indent Indent55053-3 | Participation in Assessment | |||
| Indent Indent Indent55054-1 | Resident participated in assessment | |||
| Indent Indent Indent55074-9 | Family or significant other participated in assessment | |||
| Indent Indent Indent58221-3 | Guardian or legally authorized representative participated in assessment | |||
| Indent Indent55056-6 | Resident's Overall Expectation | |||
| Indent Indent Indent55057-4 | Select one for resident's overall goal established during assessment process | |||
| Indent Indent Indent55058-2 | Indicate information source for Q0300A | |||
| Indent Indent58146-2 | Discharge Plan. Is active discharge planning already occurring for the resident to return to the community? | |||
| Indent Indent86795-2 | Resident's Preference to Avoid Being Asked Question Q0500B. Does the resident's clinical record document a request that this question be asked only on comprehensive assessments? | |||
| Indent Indent58149-6 | Return to Community. Do you want to talk to someone about the possiblity of leaving this facility and returning to live and receive services in the community? | |||
| Indent Indent86796-0 | Resident's Preference to Avoid Being Asked Question Q0500B Again | |||
| Indent Indent Indent86797-8 | Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? | |||
| Indent Indent Indent86798-6 | Indicate information source for Q0550A | |||
| Indent Indent58150-4 | Referral. Has a referral been made to the Local Contact Agency? | |||
| Indent87224-2 | Correction Request | |||
| Indent Indent85632-8 | Type of Provider | |||
| Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent45392-8 | Patient First (Given) name | |||
| Indent Indent Indent45394-4 | Patient Last (Family) name | |||
| Indent Indent46098-0 | Gender | |||
| Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent45396-9 | Social Security Number | |||
| Indent Indent87227-5 | Type of Assessment | |||
| Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent54585-5 | PPS Other Medicare Required Assessment - OMRA | |||
| Indent Indent Indent58107-4 | Is this a Swing Bed clinical change assessment? | |||
| Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..6 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent87223-4 | Assessment Administration | |||
| Indent Indent55064-0 | Medicare Part A Billing | |||
| Indent Indent Indent55065-7 | Medicare Part A HIPPS code | |||
| Indent Indent Indent55066-5 | RUG version code | |||
| Indent Indent Indent58421-9 | Is this a Medicare Short Stay assessment? | |||
| Indent Indent59375-6 | Medicare Part A Non-Therapy Billing | |||
| Indent Indent Indent58210-6 | Medicare Part A non-therapy HIPPS code | |||
| Indent Indent Indent58211-4 | RUG version code | |||
| Indent Indent55067-3 | State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent55068-1 | RUG Case Mix group | |||
| Indent Indent Indent55069-9 | RUG version code | |||
| Indent Indent58422-7 | Alternate State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent58212-2 | RUG Case Mix Group | |||
| Indent Indent Indent58213-0 | RUG version code | |||
| Indent Indent55070-7 | Insurance Billing | |||
| Indent Indent Indent55071-5 | RUG billing code | |||
| Indent Indent Indent55072-3 | RUG billing version |
Fully-Specified Name
- Component
- MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.64
- Last Updated
- Version 2.73
- Change Reason
- Release 2.73: Status: LOINC will keep most current version and one prior version of CMS assessments active and discourage all older versions.;
- Order vs. Observation
- Order
- Panel Type
- Panel
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=88955-0
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright