LOINC
Version 2.66

90475-5MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]Active

Component
MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CMS Assessment

Panel Hierarchy
Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
Indent90500-0 Identification Information
IndentIndent58198-3 Type of Record
IndentIndent54581-4 Facility Provider Numbers
IndentIndentIndent76468-8 National Provider Identifier (NPI)
IndentIndentIndent69417-4 CMS Certification Number (CCN)
IndentIndentIndent45398-5 State Provider Number
IndentIndent85632-8 Type of Provider
IndentIndent90521-6 Optional State Assessment
IndentIndentIndent90522-4 Is this assessment for state payment purposes only?
IndentIndent90489-6 Type of Assessment
IndentIndentIndent54583-0 Federal OBRA Reason for Assessment
IndentIndentIndent54584-8 PPS Assessment
IndentIndentIndent54587-1 Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
IndentIndentIndent58108-2 Entry/discharge reporting
IndentIndentIndent71440-2 Type of discharge
IndentIndentIndent90525-7 Is this a SNF Part A Interrupted Stay?
IndentIndentIndent86525-3 Is this a SNF Part A PPS Discharge Assessment?
IndentIndent86526-1 Unit Certification or Licensure Designation
IndentIndent54503-8 Legal Name of Resident
IndentIndentIndent45392-8 First name
IndentIndentIndent45393-6 Middle initial
IndentIndentIndent45394-4 Last name
IndentIndentIndent45395-1 Suffix
IndentIndent45966-9 Social Security and Medicare Numbers
IndentIndentIndent45396-9 Social Security Number
IndentIndentIndent45397-7 Medicare number
IndentIndent45400-9 Medicaid Number
IndentIndent46098-0 Gender
IndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndent59362-4 Race/Ethnicity 1..6
IndentIndent54505-3 Language
IndentIndentIndent54588-9 Does the resident need or want an interpreter to communicate with a doctor or health care staff?
IndentIndentIndent54899-0 Preferred language
IndentIndent45404-1 Marital Status
IndentIndent54506-1 Optional Resident Items
IndentIndentIndent46106-1 Medical record number
IndentIndentIndent45403-3 Room number
IndentIndentIndent52462-9 Name by which resident prefers to be addressed
IndentIndentIndent21843-8 Lifetime occupation(s)
IndentIndent86528-7 Most Recent Admission/Entry or Reentry into this Facility
IndentIndentIndent50786-3 Entry Date {mm/dd/yyyy}
IndentIndentIndent54590-5 Type of Entry
IndentIndentIndent85398-6 Entered From
IndentIndent52455-3 Admission Date (Date this episode of care in this facility began) {mm/dd/yyyy}
IndentIndent52525-3 Discharge Date {mm/dd/yyyy}
IndentIndent55128-3 Discharge Status
IndentIndent54592-1 Previous Assessment Reference Date for Significant Correction {mm/dd/yyyy}
IndentIndent54593-9 Assessment Reference Date. Observation end date {mm/dd/yyyy}
IndentIndent54507-9 Medicare Stay
IndentIndentIndent54594-7 Has the resident had a Medicare-covered stay since the most recent entry?
IndentIndentIndent54595-4 Start date of most recent Medicare stay {mm/dd/yyyy}
IndentIndentIndent54596-2 End date of most recent Medicare stay {mm/dd/yyyy}
Indent54508-7 Hearing, Speech, and Vision
IndentIndent54597-0 Comatose. Persistent vegetative state/no discernible consciousness
IndentIndent54598-8 Hearing. Ability to hear (with hearing aid or hearing appliances if normally used)
IndentIndent54599-6 Hearing Aid. Hearing aid or other hearing appliance used in completing B0200, Hearing
IndentIndent54600-2 Speech Clarity. Select best description of speech pattern
IndentIndent54601-0 Makes Self Understood. Ability to express ideas and wants, consider both verbal and non-verbal expression
IndentIndent54602-8 Ability to Understand Others. Understanding verbal content, however able (with hearing aid or device if used)
IndentIndent54603-6 Vision. Ability to see in adequate light (with glasses or other visual appliances)
IndentIndent54604-4 Corrective Lenses. Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision
Indent86529-5 Cognitive Patterns
IndentIndent54605-1 Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
IndentIndent52491-8 Brief Interview for Mental Status (BIMS)
IndentIndentIndent52731-7 Repetition of Three Words. Number of words repeated after first attempt
IndentIndentIndent54510-3 Temporal Orientation (orientation to year, month, and day)
IndentIndentIndentIndent52732-5 Able to report correct year
IndentIndentIndentIndent52733-3 Able to report correct month
IndentIndentIndentIndent54609-3 Able to report correct day of the week
IndentIndentIndent52493-4 Recall
IndentIndentIndentIndent52735-8 Able to recall "sock"
IndentIndentIndentIndent52736-6 Able to recall "blue"
IndentIndentIndentIndent52737-4 Able to recall "bed"
IndentIndentIndent54614-3 BIMS Summary Score {score}
IndentIndent54615-0 Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted?
IndentIndent86595-6 Staff Assessment for Mental Status
IndentIndentIndent54616-8 Short-term Memory OK. Seems or appears to recall after 5 minutes
IndentIndentIndent54617-6 Long-term Memory OK. Seems or appears to recall long past
IndentIndentIndent86583-2 Memory/Recall Ability 1..4
IndentIndentIndent54624-2 Cognitive Skills for Daily Decision Making. Made decisions regarding tasks of daily life
IndentIndent86584-0 Delirium
IndentIndentIndent86585-7 Signs and Symptoms of Delirium (from CAM)
IndentIndentIndentIndent54632-5 Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the resident's baseline?
IndentIndentIndentIndent54628-3 Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?
IndentIndentIndentIndent54629-1 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)?
IndentIndentIndentIndent54630-9 Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by any of the following criteria?
Indent90482-1 Mood
IndentIndent54634-1 Should Resident Mood Interview be Conducted?
IndentIndent54635-8 Resident Mood Interview (PHQ-9)
IndentIndentIndent86843-0 Symptom Presence
IndentIndentIndentIndent54636-6 Little interest or pleasure in doing things
IndentIndentIndentIndent54638-2 Feeling down, depressed or hopeless
IndentIndentIndentIndent54640-8 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54642-4 Feeling tired or having little energy
IndentIndentIndentIndent54644-0 Poor appetite or overeating
IndentIndentIndentIndent54646-5 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
IndentIndentIndentIndent54648-1 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54650-7 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
IndentIndentIndentIndent54652-3 Thoughts that you would be better off dead, or of hurting yourself in some way
IndentIndentIndent86844-8 Symptom Frequency
IndentIndentIndentIndent54637-4 Little interest or pleasure in doing things
IndentIndentIndentIndent54639-0 Feeling down, depressed or hopeless
IndentIndentIndentIndent54641-6 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54643-2 Feeling tired or having little energy
IndentIndentIndentIndent54645-7 Poor appetite or overeating
IndentIndentIndentIndent54647-3 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
IndentIndentIndentIndent54649-9 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54651-5 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
IndentIndentIndentIndent54653-1 Thoughts that you would be better off dead, or of hurting yourself in some way
IndentIndent54654-9 Total Severity Score {score}
IndentIndent54657-2 Staff Assessment of Resident Mood (PHQ-9-OV)
IndentIndentIndent86833-1 Symptom Presence
IndentIndentIndentIndent54658-0 Little interest or pleasure in doing things
IndentIndentIndentIndent54660-6 Feeling or appearing down, depressed, or hopeless
IndentIndentIndentIndent54662-2 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54664-8 Feeling tired or having little energy
IndentIndentIndentIndent54666-3 Poor appetite or overeating
IndentIndentIndentIndent54668-9 Indicating that s/he feels bad about self, is a failure, or has let self or family down
IndentIndentIndentIndent54670-5 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54672-1 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
IndentIndentIndentIndent54673-9 States that life isn't worth living, wishes for death, or attempts to harm self
IndentIndentIndentIndent54675-4 Being short-tempered, easily annoyed
IndentIndentIndent86891-9 Symptom Frequency
IndentIndentIndentIndent54659-8 Little interest or pleasure in doing things
IndentIndentIndentIndent54661-4 Feeling or appearing down, depressed, or hopeless
IndentIndentIndentIndent54663-0 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54665-5 Feeling tired or having little energy
IndentIndentIndentIndent54667-1 Poor appetite or overeating
IndentIndentIndentIndent54669-7 Indicating that s/he feels bad about self, is a failure, or has let self or family down
IndentIndentIndentIndent54671-3 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54904-8 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
IndentIndentIndentIndent54674-7 States that life isn't worth living, wishes for death, or attempts to harm self
IndentIndentIndentIndent54676-2 Being short-tempered, easily annoyed
IndentIndent54677-0 Total Severity Score {score}
Indent86815-8 Behavior
IndentIndent86597-2 Potential Indicators of Psychosis 1..2
IndentIndent54514-5 Behavioral Symptom - Presence & Frequency
IndentIndentIndent54682-0 Physical behavioral symptoms directed toward others d/(7.d)
IndentIndentIndent54683-8 Verbal behavioral symptoms directed toward others d/(7.d)
IndentIndentIndent54684-6 Other behavioral symptoms not directed toward others d/(7.d)
IndentIndent54692-9 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)
IndentIndent54693-7 Wandering - Presence & Frequency. Has the resident wandered? d/(7.d)
Indent86816-6 Functional status
IndentIndent86880-2 Activities of Daily Living (ADL) Assistance. Self-Performance
IndentIndentIndent45588-1 Bed mobility
IndentIndentIndent45590-7 Transfer
IndentIndentIndent45592-3 Walk in room
IndentIndentIndent45594-9 Walk in corridor
IndentIndentIndent45596-4 Locomotion on unit
IndentIndentIndent45598-0 Locomotion off unit
IndentIndentIndent45600-4 Dressing
IndentIndentIndent45602-0 Eating
IndentIndentIndent45604-6 Toilet use
IndentIndentIndent45606-1 Personal hygiene
IndentIndent86881-0 Activities of Daily Living (ADL) Assistance. Support Provided
IndentIndentIndent45589-9 Bed mobility
IndentIndentIndent45591-5 Transfer
IndentIndentIndent45593-1 Walk in room
IndentIndentIndent45595-6 Walk in corridor
IndentIndentIndent45597-2 Locomotion on unit
IndentIndentIndent45599-8 Locomotion off unit
IndentIndentIndent45601-2 Dressing
IndentIndentIndent45603-8 Eating
IndentIndentIndent45605-3 Toilet use
IndentIndentIndent45607-9 Personal hygiene
IndentIndent46008-9 Bathing
IndentIndentIndent45608-7 Self-performance
IndentIndentIndent45609-5 Support provided
IndentIndent54524-4 Balance During Transitions and Walking
IndentIndentIndent54749-7 Moving from seated to standing position
IndentIndentIndent54750-5 Walking (with assistive device if used)
IndentIndentIndent54751-3 Turning around and facing the opposite direction while walking
IndentIndentIndent54752-1 Moving on and off toilet
IndentIndentIndent54753-9 Surface-to-surface transfer (transfer between bed and chair or wheelchair)
IndentIndent92908-3 Functional Limitation in Range of Motion
IndentIndentIndent92850-7 Upper extremity (shoulder, elbow, wrist, hand)
IndentIndentIndent92851-5 Lower extremity (hip, knee, ankle, foot)
IndentIndent86602-0 Mobility Devices 1..4
Indent88482-5 Functional Abilities and Goals - Admission (Start of SNF PPS Stay)
IndentIndent83239-4 Prior Functioning: Everyday Activities
IndentIndentIndent85070-1 Self-Care
IndentIndentIndent85071-9 Indoor Mobility (Ambulation)
IndentIndentIndent85072-7 Stairs
IndentIndentIndent85073-5 Functional Cognition
IndentIndent83234-5 Prior Device Use 1..5
IndentIndent83233-7 Self-Care - Admission Performance
IndentIndentIndent83232-9 Eating
IndentIndentIndent83230-3 Oral hygiene
IndentIndentIndent83228-7 Toileting hygiene
IndentIndentIndent83226-1 Shower/bathe self
IndentIndentIndent83224-6 Upper body dressing
IndentIndentIndent83222-0 Lower body dressing
IndentIndentIndent83220-4 Putting on/taking off footwear
IndentIndent85054-5 Self-Care - Discharge Goal
IndentIndentIndent83231-1 Eating
IndentIndentIndent83229-5 Oral hygiene
IndentIndentIndent83227-9 Toileting hygiene
IndentIndentIndent83225-3 Shower/bathe self
IndentIndentIndent83223-8 Upper body dressing
IndentIndentIndent83221-2 Lower body dressing
IndentIndentIndent83219-6 Putting on/taking off footwear
IndentIndent88330-6 Mobility - Admission Performance
IndentIndentIndent83218-8 Roll left and right
IndentIndentIndent83216-2 Sit to lying
IndentIndentIndent83214-7 Lying to sitting on side of bed
IndentIndentIndent83212-1 Sit to stand
IndentIndentIndent83210-5 Chair/bed-to-chair transfer
IndentIndentIndent83208-9 Toilet transfer
IndentIndentIndent83206-3 Car transfer
IndentIndentIndent83204-8 Walk 10 feet
IndentIndentIndent83202-2 Walk 50 feet with two turns
IndentIndentIndent83200-6 Walk 150 feet
IndentIndentIndent83198-2 Walking 10 feet on uneven surfaces
IndentIndentIndent83196-6 1 step (curb)
IndentIndentIndent83194-1 4 steps
IndentIndentIndent83192-5 12 steps
IndentIndentIndent83190-9 Picking up object
IndentIndentIndent83271-7 Does the resident use a wheelchair and/or scooter?
IndentIndentIndent83188-3 Wheel 50 feet with two turns
IndentIndentIndent83272-5 Indicate the type of wheelchair or scooter used
IndentIndentIndent83235-2 Wheel 150 feet
IndentIndentIndent83272-5 Indicate the type of wheelchair or scooter used
IndentIndent85056-0 Mobility - Discharge Goal
IndentIndentIndent83217-0 Roll left and right
IndentIndentIndent83215-4 Sit to lying
IndentIndentIndent83213-9 Lying to sitting on side of bed
IndentIndentIndent83211-3 Sit to stand
IndentIndentIndent83209-7 Chair/Bed-to-chair transfer
IndentIndentIndent83207-1 Toilet transfer
IndentIndentIndent83205-5 Car transfer
IndentIndentIndent83203-0 Walk 10 feet
IndentIndentIndent83201-4 Walk 50 feet with two turns
IndentIndentIndent83199-0 Walk 150 feet
IndentIndentIndent83197-4 Walking 10 feet on uneven surfaces
IndentIndentIndent83195-8 1 step (curb)
IndentIndentIndent83193-3 4 steps
IndentIndentIndent83191-7 12 steps
IndentIndentIndent83189-1 Picking up object
IndentIndentIndent83187-5 Wheel 50 feet with two turns
IndentIndentIndent83236-0 Wheel 150 feet
Indent88483-3 Functional Abilities and Goals - Discharge (End of SNF PPS Stay)
IndentIndent83254-3 Self-Care - Discharge Performance
IndentIndentIndent83232-9 Eating
IndentIndentIndent83230-3 Oral hygiene
IndentIndentIndent83228-7 Toileting hygiene
IndentIndentIndent83226-1 Shower/bathe self
IndentIndentIndent83224-6 Upper body dressing
IndentIndentIndent83222-0 Lower body dressing
IndentIndentIndent83220-4 Putting on/taking off footwear
IndentIndent88331-4 Mobility - Discharge Performance
IndentIndentIndent83218-8 Roll left and right
IndentIndentIndent83216-2 Sit to lying
IndentIndentIndent83214-7 Lying to sitting on side of bed
IndentIndentIndent83212-1 Sit to stand
IndentIndentIndent83210-5 Chair/bed-to-chair transfer
IndentIndentIndent83208-9 Toilet transfer
IndentIndentIndent83206-3 Car transfer
IndentIndentIndent83204-8 Walk 10 feet
IndentIndentIndent83202-2 Walk 50 feet with two turns
IndentIndentIndent83200-6 Walk 150 feet
IndentIndentIndent83198-2 Walking 10 feet on uneven surfaces
IndentIndentIndent83196-6 1 step (curb)
IndentIndentIndent83194-1 4 steps
IndentIndentIndent83192-5 12 steps
IndentIndentIndent83190-9 Picking up object
IndentIndentIndent83271-7 Does the resident use a wheelchair and/or scooter?
IndentIndentIndent83188-3 Wheel 50 feet with two turns
IndentIndentIndent83272-5 Indicate the type of wheelchair or scooter used
IndentIndentIndent83235-2 Wheel 150 feet
IndentIndentIndent83272-5 Indicate the type of wheelchair or scooter used
Indent89049-1 Bladder and Bowel
IndentIndent86624-4 Appliances 1..4
IndentIndent86866-1 Urinary Toileting Program
IndentIndentIndent54767-9 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?
IndentIndentIndent54769-5 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?
IndentIndent54770-3 Urinary Continence 1..1
IndentIndent54771-1 Bowel Continence 1..1
IndentIndent88695-2 Bowel Toileting Program. Is a toileting program currently being used to manage the resident's bowel continence?
Indent90485-4 Active Diagnoses
IndentIndent89045-9 Indicate the resident's primary medical condition category 1..1
IndentIndent52797-8 ICD Code
IndentIndent86671-5 Active Diagnoses in the last 7 days 1..*
IndentIndent52797-8 Additional active diagnoses 0..10
Indent90487-0 Health Conditions
IndentIndent54557-4 Pain Management
IndentIndentIndent71447-7 At any time in the last 5 days, has the resident: Received scheduled pain medication regimen?
IndentIndentIndent71448-5 At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined?
IndentIndentIndent71449-3 At any time in the last 5 days, has the resident: Received non-medication intervention for pain?
IndentIndent54828-9 Should Pain Assessment Interview be Conducted?
IndentIndent54558-2 Pain Assessment Interview
IndentIndentIndent54829-7 Pain Presence. Have you had pain or hurting at any time in the last 5 days?
IndentIndentIndent54830-5 Pain Frequency. How much of the time have you experienced pain or hurting over the last 5 days?
IndentIndentIndent54559-0 Pain Effect on Function
IndentIndentIndentIndent54831-3 Over the past 5 days, has pain made it hard for you to sleep at night?
IndentIndentIndentIndent54832-1 Over the past 5 days, have you limited your day-to-day activities because of pain?
IndentIndentIndent54560-8 Pain Intensity
IndentIndentIndentIndent54833-9 Numeric Rating Scale (00-10)
IndentIndentIndentIndent54834-7 Verbal Descriptor Scale
IndentIndent58117-3 Should the Staff Assessment for Pain be Conducted?
IndentIndent86672-3 Staff Assessment for Pain
IndentIndentIndent86673-1 Indicators of Pain or Possible Pain in the last 5 days 1..4
IndentIndentIndent58118-1 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)
IndentIndent86868-7 Other Health Conditions
IndentIndentIndent86675-6 Shortness of Breath (dyspnea) 1..3
IndentIndentIndent54846-1 Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?
IndentIndentIndent86676-4 Problem Conditions 1..4
IndentIndentIndent54849-5 Fall History on Admission/Entry or Reentry
IndentIndentIndentIndent54850-3 Did the resident have a fall any time in the last month prior to admission/entry or reentry?
IndentIndentIndentIndent54851-1 Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
IndentIndentIndentIndent54852-9 Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
IndentIndentIndent54853-7 Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent?
IndentIndentIndent54854-5 Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent
IndentIndentIndentIndent54855-2 No injury
IndentIndentIndentIndent54856-0 Injury (except major)
IndentIndentIndentIndent54857-8 Major injury
IndentIndent83274-1 Prior Surgery. Did the resident have major surgery during the 100 days prior to admission?
IndentIndent90542-2 Recent Surgery Requiring Active SNF Care-Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?
IndentIndent90745-1 Surgical Procedures
Indent90483-9 Swallowing/Nutritional Status
IndentIndent86677-2 Swallowing Disorder. Signs and symptoms of possible swallowing disorder 1..4
IndentIndent54567-3 Height and Weight
IndentIndentIndent3137-7 Height (in inches) [in_us];cm
IndentIndentIndent3141-9 Weight (in pounds) [lb_av];kg
IndentIndent54863-6 Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in last 6 months
IndentIndent86678-0 Weight Gain. Gain of 5% or more in the last month or gain of 10% or more in last 6 months
IndentIndent54568-1 Nutritional Approaches
IndentIndentIndent71444-4 Nutritional Approaches. While NOT a Resident 0..2
IndentIndentIndent71445-1 Nutritional Approaches. While a Resident 1..4
IndentIndent90543-0 Percent Intake by Artificial Route
IndentIndentIndent86681-4 Proportion of total calories the resident received through parenteral or tube feeding. While a Resident
IndentIndentIndent86687-1 Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days
IndentIndentIndent86683-0 Average fluid intake per day by IV or tube feeding. While a Resident
IndentIndentIndent86684-8 Average fluid intake per day by IV or tube feeding. During Entire 7 Days
Indent86685-5 Oral/Dental Status
IndentIndent86706-9 Dental 1..2
Indent88960-0 Skin Conditions
IndentIndent86708-5 Determination of Pressure Ulcer/Injury Risk 1..3
IndentIndent57280-0 Risk of Pressure Ulcers/Injuries. Is this resident at risk of developing pressure ulcers/injuries?
IndentIndent58214-8 Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries?
IndentIndent88961-8 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
IndentIndentIndent54884-2 Number of Stage 1 pressure injuries {#}
IndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndent54886-7 Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent54887-5 Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54890-9 Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent54893-3 Number of unstageable pressure ulcers/injuries due to non-removable dressing/device {#}
IndentIndentIndent54894-1 Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndent54947-7 Number of these unstageable pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent54950-1 Number of unstageable pressure injuries presenting as deep tissue injury {#}
IndentIndentIndent54951-9 Number of these unstageable pressure injuries that were present upon admission/entry or reentry {#}
IndentIndent54970-9 Number of Venous and Arterial Ulcers {#}
IndentIndent88696-0 Other Ulcers, Wounds and Skin Problems 1..8
IndentIndent86748-1 Skin and Ulcer/Injury Treatments 1..9
Indent88962-6 Medications
IndentIndent54982-4 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)
IndentIndent58217-1 Insulin
IndentIndentIndent58127-2 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)
IndentIndentIndent58128-0 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)
IndentIndent88290-2 Medications Received
IndentIndentIndent86751-5 Antipsychotic d/(7.d)
IndentIndentIndent86752-3 Antianxiety d/(7.d)
IndentIndentIndent86753-1 Antidepressant d/(7.d)
IndentIndentIndent86754-9 Hypnotic d/(7.d)
IndentIndentIndent86755-6 Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin) d/(7.d)
IndentIndentIndent86756-4 Antibiotic d/(7.d)
IndentIndentIndent86757-2 Diuretic d/(7.d)
IndentIndentIndent88291-0 Opiod d/(7.d)
IndentIndent88295-1 Antipsychotic Medication Review
IndentIndentIndent88296-9 Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent?
IndentIndentIndent88297-7 Has a gradual dose reduction (GDR) been attempted?
IndentIndentIndent88298-5 Date of last attempted GDR {mm/dd/yyyy}
IndentIndentIndent88299-3 Physician documented GDR as clinically contraindicated
IndentIndentIndent88300-9 Date physician documented GDR as clinically contraindicated {mm/dd/yyyy}
IndentIndent57255-2 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?
IndentIndent57281-8 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?
IndentIndent57256-0 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?
Indent90515-8 Special Treatments, Procedures, and Programs
IndentIndent86759-8 Special Treatments, Procedures, and Programs
IndentIndentIndent86760-6 While NOT a Resident 0..9
IndentIndentIndent86761-4 While a Resident 0..11
IndentIndent69339-0 Influenza Vaccine
IndentIndentIndent55019-4 Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?
IndentIndentIndent58131-4 Date influenza vaccine received {mm/dd/yyyy}
IndentIndentIndent55020-2 If influenza vaccine not received, state reason:
IndentIndent55021-0 Pneumococcal Vaccine
IndentIndentIndent55022-8 Is the resident's Pneumococcal vaccination up to date?
IndentIndentIndent45956-0 If Pneumococcal vaccine not received, state reason:
IndentIndent86841-4 Therapies
IndentIndentIndent86763-0 Speech-Language Pathology and Audiology Services
IndentIndentIndentIndent58218-9 Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days min
IndentIndentIndentIndent58133-0 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
IndentIndentIndentIndent58134-8 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
IndentIndentIndentIndent86765-5 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
IndentIndentIndentIndent45760-6 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)
IndentIndentIndentIndent55025-1 Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started {mm/dd/yyyy}
IndentIndentIndentIndent55026-9 Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended {mm/dd/yyyy}
IndentIndentIndent86767-1 Occupational Therapy
IndentIndentIndentIndent58219-7 Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days min
IndentIndentIndentIndent58136-3 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
IndentIndentIndentIndent58137-1 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
IndentIndentIndentIndent86764-8 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
IndentIndentIndentIndent45762-2 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)
IndentIndentIndentIndent55027-7 Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started {mm/dd/yyyy}
IndentIndentIndentIndent55028-5 Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended {mm/dd/yyyy}
IndentIndentIndent86768-9 Physical Therapy
IndentIndentIndentIndent58220-5 Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days min
IndentIndentIndentIndent58139-7 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
IndentIndentIndentIndent58140-5 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
IndentIndentIndentIndent86766-3 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
IndentIndentIndentIndent45764-8 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)
IndentIndentIndentIndent55029-3 Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started {mm/dd/yyyy}
IndentIndentIndentIndent55030-1 Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended {mm/dd/yyyy}
IndentIndentIndent86849-7 Respiratory therapy
IndentIndentIndentIndent45766-3 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)
IndentIndentIndent86850-5 Psychological therapy
IndentIndentIndentIndent45768-9 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)
IndentIndent86769-7 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
IndentIndent90544-8 Part A Therapies
IndentIndentIndent90545-5 Speech-Language Pathology and Audiology Services
IndentIndentIndentIndent90539-8 Individual minutes - record the total number of minutes this therapy was administered to the resident individually since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90536-4 Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90538-0 Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90537-2 Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90551-3 Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the resident's most recent Medicare Part A stay (A2400B) d/{#}
IndentIndentIndent90546-3 Occupational Therapy
IndentIndentIndentIndent90531-5 Individual minutes - record the total number of minutes this therapy was administered to the resident individually since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90527-3 Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay (A2400B) min
IndentIndentIndentIndent90529-9 Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90528-1 Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90530-7 Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the resident's most recent Medicare Part A stay (A2400B) d/{#}
IndentIndentIndent90547-1 Physical Therapy
IndentIndentIndentIndent90535-6 Individual minutes - record the total number of minutes this therapy was administered to the resident individually since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90532-3 Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90534-9 Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90533-1 Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B)
IndentIndentIndentIndent90550-5 Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the resident's most recent Medicare Part A stay (A2400B) d/{#}
IndentIndent90548-9 Distinct Calendar Days of Part A Therapy {#}
IndentIndent86773-9 Restorative Nursing Programs
IndentIndentIndent86774-7 Technique. Range of motion (passive) d/(7.d)
IndentIndentIndent86775-4 Technique. Range of motion (active) d/(7.d)
IndentIndentIndent86776-2 Technique. Splint or brace assistance d/(7.d)
IndentIndentIndent86777-0 Training and Skill Practice In: Bed mobility d/(7.d)
IndentIndentIndent86778-8 Training and Skill Practice In: Transfer d/(7.d)
IndentIndentIndent86779-6 Training and Skill Practice In: Walking d/(7.d)
IndentIndentIndent86780-4 Training and Skill Practice In: Dressing and/or grooming d/(7.d)
IndentIndentIndent86781-2 Training and Skill Practice In: Eating and/or swallowing d/(7.d)
IndentIndentIndent86782-0 Training and Skill Practice In: Amputation/prostheses care d/(7.d)
IndentIndentIndent86783-8 Training and Skill Practice In: Communication d/(7.d)
IndentIndent55040-0 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)
IndentIndent55041-8 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
IndentIndent86785-3 Physical Restraints
IndentIndentIndent86786-1 Used in Bed. Bed rail d/(7.d)
IndentIndentIndent86787-9 Used in Bed. Trunk restraint d/(7.d)
IndentIndentIndent86788-7 Used in Bed. Limb restraint d/(7.d)
IndentIndentIndent86789-5 Used in Bed. Other d/(7.d)
IndentIndentIndent86790-3 Used in Chair or Out of Bed. Trunk restraint d/(7.d)
IndentIndentIndent86791-1 Used in Chair or Out of Bed. Limb restraint d/(7.d)
IndentIndentIndent86792-9 Used in Chair or Out of Bed. Chair prevents rising d/(7.d)
IndentIndentIndent86793-7 Used in Chair or Out of Bed. Other d/(7.d)
IndentIndent88309-0 Alarms
IndentIndentIndent88310-8 Bed alarm
IndentIndentIndent88311-6 Chair alarm
IndentIndentIndent88312-4 Floor mat alarm
IndentIndentIndent88313-2 Motion sensor alarm
IndentIndentIndent88314-0 Wander/elopement alarm
IndentIndentIndent88308-2 Other alarm
Indent86794-5 Participation in Assessment and Goal Setting
IndentIndent55053-3 Participation in Assessment
IndentIndentIndent55054-1 Resident participated in assessment
IndentIndentIndent55074-9 Family or significant other participated in assessment
IndentIndentIndent58221-3 Guardian or legally authorized representative participated in assessment
IndentIndent55056-6 Resident's Overall Expectation
IndentIndentIndent55057-4 Select one for resident's overall goal established during assessment process
IndentIndentIndent55058-2 Indicate information source for Q0300A
IndentIndent58146-2 Discharge Plan. Is active discharge planning already occurring for the resident to return to the community?
IndentIndent86795-2 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?
IndentIndent58149-6 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?
IndentIndent86796-0 Resident's Preference to Avoid Being Asked Question Q0500B Again
IndentIndentIndent86797-8 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?
IndentIndentIndent86798-6 Indicate information source for Q0550A
IndentIndent58150-4 Referral. Has a referral been made to the Local Contact Agency?
Indent90490-4 Correction Request
IndentIndent85632-8 Type of Provider
IndentIndent87226-7 Name of Resident
IndentIndentIndent45392-8 First name
IndentIndentIndent45394-4 Last name
IndentIndent46098-0 Gender
IndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndent45396-9 Social Security Number
IndentIndent90522-4 Optional State Assessment. Is this assessment for state payment purposes only?
IndentIndent90492-0 Type of Assessment
IndentIndentIndent54583-0 Federal OBRA Reason for Assessment
IndentIndentIndent54584-8 PPS Assessment
IndentIndentIndent58108-2 Entry/discharge reporting
IndentIndentIndent86525-3 Is this a SNF Part A PPS Discharge Assessment?
IndentIndent87216-8 Date on existing record to be modified/inactivated
IndentIndentIndent54593-9 Assessment Reference Date {mm/dd/yyyy}
IndentIndentIndent52525-3 Discharge Date {mm/dd/yyyy}
IndentIndentIndent50786-3 Entry Date {mm/dd/yyyy}
IndentIndent87209-3 Correction Attestation Section
IndentIndentIndent58200-7 Correction Number {#}
IndentIndentIndent87217-6 Reasons for Modification 1..5
IndentIndentIndent87225-9 Reasons for Inactivation 1..2
IndentIndentIndent87218-4 RN Assessment Coordinator Attestation of Completion
IndentIndentIndentIndent87219-2 Attesting individual's first name
IndentIndentIndentIndent87220-0 Attesting individual's last name
IndentIndentIndentIndent87221-8 Attesting individual's title
IndentIndentIndentIndent87222-6 Attestation date {mm/dd/yyyy}
Indent90497-9 Assessment Administration
IndentIndent90498-7 Medicare Part A Billing
IndentIndentIndent55065-7 Medicare Part A HIPPS code
IndentIndentIndent55081-4 Version code
IndentIndent93053-7 State Medicaid Billing (if required by the state)
IndentIndentIndent55068-1 Case Mix group
IndentIndentIndent55081-4 Version code
IndentIndent93052-9 Alternate State Medicaid Billing (if required by the state)
IndentIndentIndent58212-2 Case Mix group
IndentIndentIndent55081-4 Version code
IndentIndent93051-1 Insurance Billing
IndentIndentIndent55071-5 Billing code
IndentIndentIndent55081-4 Billing version

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.66
Last Updated
Version 2.66
Order vs. Observation
Order
Panel Type
Panel

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=90475-5