LOINC
Version 2.72

90481-3MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set [CMS Assessment]Active

Term Description

This panel should be used for CMS MDS 3.0 v1.17.1 OSA assessments performed between October 1, 2019 and September 30, 2020 and CMS MDS 3.0 v1.17.2 OSA assessments performed after October 1, 2020.
Source: Regenstrief LOINC

Panel Hierarchy
Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set [CMS Assessment]
Indent90504-2 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
IndentIndent90523-2 Optional State Assessment
IndentIndentIndent90522-4 Is this assessment for state payment purposes only?
IndentIndentIndent90524-0 Assessment type
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)
IndentIndent50786-3 Most Recent Admission/Entry or Reentry into this Facility. Entry Date {mm/dd/yyyy}
IndentIndent52455-3 Admission Date (Date this episode of care in this facility began) {mm/dd/yyyy}
IndentIndent54593-9 Assessment Reference Date. Observation end date {mm/dd/yyyy}
IndentIndent90494-6 Medicare Stay
IndentIndentIndent54595-4 Start date of most recent Medicare stay {mm/dd/yyyy}
IndentIndentIndent54596-2 End date of most recent Medicare stay {mm/dd/yyyy}
Indent90505-9 Hearing, Speech, and Vision
IndentIndent54597-0 Comatose. Persistent vegetative state/no discernible consciousness
IndentIndent95737-3 Makes Self Understood. Ability to express ideas and wants, consider both verbal and non-verbal expression
Indent93050-3 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?
IndentIndent86814-1 Staff Assessment for Mental Status
IndentIndentIndent54616-8 Short-term Memory OK. Seems or appears to recall after 5 minutes
IndentIndentIndent54624-2 Cognitive Skills for Daily Decision Making. Made decisions regarding tasks of daily life
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)
Indent86817-4 Functional Status
IndentIndent86885-1 Activities of Daily Living (ADL) Assistance. Self-Performance
IndentIndentIndent45588-1 Bed mobility
IndentIndentIndent45590-7 Transfer
IndentIndentIndent45602-0 Eating
IndentIndentIndent45604-6 Toilet use
IndentIndent86886-9 Activities of Daily Living (ADL) Assistance. Support Provided
IndentIndentIndent45589-9 Bed mobility
IndentIndentIndent45591-5 Transfer
IndentIndentIndent45603-8 Eating
IndentIndentIndent45605-3 Toilet use
Indent90506-7 Bladder and Bowel
IndentIndent54769-5 Urinary Toileting Program. 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?
IndentIndent88695-2 Bowel Toileting Program. Is a toileting program currently being used to manage the resident's bowel continence?
Indent90508-3 Active Diagnoses
IndentIndent86671-5 Active Diagnoses in the last 7 days 1..*
Indent86888-5 Health conditions
IndentIndent86889-3 Other Health Conditions
IndentIndentIndent86675-6 Shortness of Breath (dyspnea) 1..1
IndentIndentIndent86676-4 Problem Conditions 1..4
Indent90510-9 Swallowing/Nutritional Status
IndentIndent54863-6 Weight Loss. Loss of 5% or more in the last month or loss 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..2
IndentIndent91555-3 Percent Intake by Artificial Route
IndentIndentIndent86687-1 Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days
IndentIndentIndent86684-8 Average fluid intake per day by IV or tube feeding. During Entire 7 Days mL/d;L/d
Indent90512-5 Skin Conditions
IndentIndent58214-8 Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries?
IndentIndent90511-7 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 {#}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar {#}
IndentIndent54970-9 Number of Venous and Arterial Ulcers {#}
IndentIndent88696-0 Other Ulcers, Wounds and Skin Problems 1..6
IndentIndent86748-1 Skin and Ulcer/Injury Treatments 1..9
Indent86831-5 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)
Indent90518-2 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 1..10
IndentIndent91577-7 Therapies
IndentIndentIndent58132-2 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
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}
IndentIndentIndent58135-5 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
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}
IndentIndentIndent58138-9 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
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)
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
IndentIndent86772-1 Resumption of Therapy. 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?
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)
Indent90491-2 Correction Request
IndentIndent85632-8 Type of Provider
IndentIndent87226-7 Name of Resident
IndentIndentIndent45392-8 Patient First (Given) name
IndentIndentIndent45394-4 Patient Last (Family) name
IndentIndent46098-0 Gender
IndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndent45396-9 Social Security Number
IndentIndent90523-2 Optional State Assessment
IndentIndentIndent90522-4 Is this assessment for state payment purposes only?
IndentIndentIndent90524-0 Assessment type
IndentIndent54593-9 Date on existing record to be modified/inactivated. Assessment Reference 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}
Indent90496-1 Assessment Administration
IndentIndent91581-9 State Medicaid Billing (if required by the state)
IndentIndentIndent55068-1 Case Mix group
IndentIndentIndent55081-4 Version code
IndentIndentIndent90549-7 Is this a Short Stay assessment?
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

Fully-Specified Name

Component
MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.66
Last Updated
Version 2.68
Change Reason
Release 2.68: DefinitionDescription: Added missing Term Description; COMPONENT: Version 1.17.2 was added to the Component because this panel now represents both versions.; Release 2.67: DefinitionDescription: Added missing Term Description
Order vs. Observation
Order
Panel Type
Panel

LOINC FHIR® API Example - CodeSystem and Questionnaire Requests Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=90481-3 https://fhir.loinc.org/Questionnaire/?url=http://loinc.org/q/90481-3