Version 2.78

95032-9 Functional Abilities and Goals

Observation ID in Form

GG

Fully-Specified Name

Component
FASI v1.0 - Functional Abilities and Goals
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95020-4 Self-Care

Observation ID in Form

GG0130

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's self-care performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Self-care
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94849-7 Self-Care.Usual

Observation ID in Form

GG0130_7

Fully-Specified Name

Component
FASI v1.0 - Self-care - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95019-6 Eating

Term Description

The patient's usual ability to use suitable utensils to bring food/liquid to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.
Source: Regenstrief LOINC

Observation ID in Form

GG0130A7

Form Context

The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the person

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Eating - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95018-8 Oral hygiene

Observation ID in Form

GG0130B7

Form Context

The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Oral hygiene - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95017-0 Toileting hygiene

Observation ID in Form

GG0130CC7

Form Context

The ability to maintain perineal/menstrual hygiene adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toileting hygiene - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95016-2 Wash upper body

Observation ID in Form

GG0130D7

Form Context

The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wash upper body - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]

95015-4 Shower/bathe self

Observation ID in Form

GG0130EE7

Form Context

The ability to bathe self including washing, rinsing, and drying self . Does not include transferring in/out of tub/shower

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Shower &or bathe self - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95014-7 Upper body dressing

Observation ID in Form

GG0130F7

Form Context

The ability to dress and undress above the waist, including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Upper body dressing - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95013-9 Lower body dressing

Observation ID in Form

GG0130G7

Form Context

The ability to dress and undress below the waist, including fasteners; does not include footwear

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lower body dressing - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95012-1 Putting on/taking off footwear

Observation ID in Form

GG0130H7

Form Context

The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Putting on &or taking off footwear - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94850-5 Self-Care.Most Dependent

Observation ID in Form

GG0130_8

Fully-Specified Name

Component
FASI v1.0 - Self-care - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94933-9 Eating

Observation ID in Form

GG0130A8

Form Context

The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the person

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Eating - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94934-7 Oral hygiene

Observation ID in Form

GG0130B8

Form Context

The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Oral hygiene - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95043-6 Toileting hygiene

Observation ID in Form

GG0130CC8

Form Context

The ability to maintain perineal/menstrual hygiene adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toileting hygiene - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94935-4 Wash upper body

Observation ID in Form

GG0130D8

Form Context

The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wash upper body - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94936-2 Shower/bathe self

Observation ID in Form

GG0130EE8

Form Context

The ability to bathe self including washing, rinsing, and drying self . Does not include transferring in/out of tub/shower

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Shower &or bathe self - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94937-0 Upper body dressing

Observation ID in Form

GG0130F8

Form Context

The ability to dress and undress above the waist, including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Upper body dressing - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94938-8 Lower body dressing

Observation ID in Form

GG0130G8

Form Context

The ability to dress and undress below the waist, including fasteners; does not include footwear

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lower body dressing - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94939-6 Putting on/taking off footwear

Observation ID in Form

GG0130H8

Form Context

The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Putting on and taking off footwear - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94876-0 Self-Care Priorities

Observation ID in Form

GG0135

Form Context

Please ask the person to describe at least one or two personal priorities in the area of self-care for the next six months. If the person does not express any personal priorities in this area, please note this below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Self-care priorities for the next 6Mo
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nar
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95023-8 Mobility

Observation ID in Form

GG0170

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's transfer/bed mobility performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Mobility
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94851-3 Mobility.Usual

Observation ID in Form

GG0170_7

Fully-Specified Name

Component
FASI v1.0 - Mobility - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95011-3 Roll left and right

Observation ID in Form

GG0170A7

Form Context

The ability to roll from lying on back to left and right side, and return to lying on back

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Roll left and right - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95010-5 Sit to lying

Observation ID in Form

GG0170B7

Form Context

The ability to move from sitting on side of bed to lying flat on the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to lying - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95009-7 Lying to sitting on side of bed

Observation ID in Form

GG0170C7

Form Context

The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor and with no back support

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lying to sitting on side of bed - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95008-9 Sit to stand

Observation ID in Form

GG0170D7

Form Context

The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to stand - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95007-1 Chair/bed-to-chair transfer

Observation ID in Form

GG0170E7

Form Context

The ability to transfer to and from a bed to a chair (or wheelchair)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Chair &or bed-to-chair transfer - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95006-3 Toilet transfer

Observation ID in Form

GG0170F7

Form Context

The ability to get on and off a toilet or commode

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toilet transfer - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95005-5 Car transfer

Observation ID in Form

GG0170G7

Form Context

The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Car transfer - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94932-1 Does the patient walk?

Observation ID in Form

GG0170HH7

Skip Logic

If 0, Skip to GG0175A. If 1, Skip to GG0175A. If 2, Continue to GG0170I.

Fully-Specified Name

Component
Does the patient walk
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.78: ANSWER_LIST_TYPE: FASI V1.1; Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL4183-1

Answer Code Score Answer ID
No, and walking goal is not clinically indicated 0 LA26845-0
No, and walking goal is clinically indicated 1 LA26846-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 2 LA33-6

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95004-8 Walks 10 feet

Observation ID in Form

GG0170I7

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0170M

Form Context

Once standing, the ability to walk at least 10 feet in a room, corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 10 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Corrected "Walks" to "Walk" to for consistency across CMS assessment forms.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95003-0 Walks 50 feet with two turns

Observation ID in Form

GG0170J7

Form Context

Once standing, the ability to walk at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 50 feet with two turns - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Corrected "Walks" to "Walk" to for consistency across CMS assessment forms.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95002-2 Walks 150 feet

Observation ID in Form

GG0170K7

Form Context

Once standing, the ability to walk at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 150 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Corrected "Walks" to "Walk" to for consistency across CMS assessment forms.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95001-4 Walks 10 feet on uneven surfaces

Observation ID in Form

GG0170L7

Form Context

The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walking 10 feet on uneven surfaces - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95000-6 1 step (curb)

Observation ID in Form

GG0170M7

Form Context

The ability to go up and down a curb or up and down one step

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down a curb &or step - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94999-0 4 steps

Observation ID in Form

GG0170N7

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0170P.

Form Context

The ability to go up and down four steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 4 steps - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94998-2 12 steps

Observation ID in Form

GG0170O7

Form Context

The ability to go up and down 12 steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 12 steps - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94997-4 Picking up object

Observation ID in Form

GG0170P7

Form Context

The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Picking up object - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94996-6 Walk indoors

Observation ID in Form

GG0170U7

Form Context

The ability to walk from room to room, around furniture and other obstacles

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks indoors - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94995-8 Carries something in both hands

Observation ID in Form

GG0170V7

Form Context

The ability to carry something in both hands while walking indoors e.g. several dishes, light laundry basket, tray with food

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Carries something in both hands - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94994-1 Walks for 15 minutes

Observation ID in Form

GG0170W7

Form Context

The ability to walk for 15 minutes without stopping or resting (e.g., department store, supermarket.)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks for 15M - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94993-3 Walks across a street

Observation ID in Form

GG0170X7

Form Context

The ability to cross street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks across a street - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94852-1 Mobility.Most Dependent

Observation ID in Form

GG0170_8

Fully-Specified Name

Component
FASI v1.0 - Mobility - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94940-4 Roll left and right

Observation ID in Form

GG0170A8

Form Context

The ability to roll from lying on back to left and right side, and return to lying on back

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Roll left and right - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94941-2 Sit to lying

Observation ID in Form

GG0170B8

Form Context

The ability to move from sitting on side of bed to lying flat on the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to lying - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94942-0 Lying to sitting on side of bed

Observation ID in Form

GG0170C8

Form Context

The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor and with no back support

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lying to sitting on side of bed - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94943-8 Sit to stand

Observation ID in Form

GG0170D8

Form Context

The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to stand - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94944-6 Chair/bed-to-chair transfer

Observation ID in Form

GG0170E8

Form Context

The ability to transfer to and from a bed to a chair (or wheelchair)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Chair &or bed-to-chair transfer - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Updated for consistency across terms and to clarify that assessment is for transfer from a chair and/or bed to a chair.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94945-3 Toilet transfer

Observation ID in Form

GG0170F8

Form Context

The ability to get on and off a toilet or commode

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toilet transfer - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94946-1 Car transfer

Observation ID in Form

GG0170G8

Form Context

The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Car transfer - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94947-9 Walks 10 feet

Observation ID in Form

GG0170I8

Form Context

Once standing, the ability to walk at least 10 feet in a room, corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 10 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94948-7 Walks 50 feet with two turns

Observation ID in Form

GG0170J8

Form Context

Once standing, the ability to walk at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 50 feet with two turns - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94949-5 Walks 150 feet

Observation ID in Form

GG0170K8

Form Context

Once standing, the ability to walk at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 150 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94950-3 Walks 10 feet on uneven surfaces

Observation ID in Form

GG0170L8

Form Context

The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walking 10 feet on uneven surfaces - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94951-1 1 step (curb)

Observation ID in Form

GG0170M8

Form Context

The ability to go up and down a curb or up and down one step

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down a curb &or step - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94952-9 4 steps

Observation ID in Form

GG0170N8

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0170P.

Form Context

The ability to go up and down four steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 4 steps - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94953-7 12 steps

Observation ID in Form

GG0170O8

Form Context

The ability to go up and down 12 steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 12 steps - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94954-5 Picking up object

Observation ID in Form

GG0170P8

Form Context

The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Picking up object - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94955-2 Walks indoors

Observation ID in Form

GG0170U8

Form Context

The ability to walk from room to room, around furniture and other obstacles

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks indoors - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94956-0 Carries something in both hands

Observation ID in Form

GG0170V8

Form Context

The ability to carry something in both hands while walking indoors e.g. several dishes, light laundry basket, tray with food

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Carries something in both hands - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94957-8 Walks for 15 minutes

Observation ID in Form

GG0170W8

Form Context

The ability to walk for 15 minutes without stopping or resting (e.g., department store, supermarket.)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks for 15M - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94958-6 Walks across a street

Observation ID in Form

GG0170X8

Form Context

The ability to cross street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks across a street - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95131-9 Mobility (Wheelchair)

Observation ID in Form

GG0175

Fully-Specified Name

Component
FASI v1.0 - Mobility (Wheelchair)
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95021-2 Does the person use a manual wheelchair?

Observation ID in Form

GG0175A

Skip Logic

If 0, Skip to GG0175F. If 1, Continue to GG0175B.

Fully-Specified Name

Component
Manual wheelchair use
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95024-6 Manual wheelchair.Usual

Observation ID in Form

GG0175_7

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's wheelchair mobility performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Manual wheelchair - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94992-5 Wheel 50 feet with two turns

Observation ID in Form

GG0175B7

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0175E

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94991-7 Wheels 150 feet

Observation ID in Form

GG0175C7

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94990-9 Wheels for 15 minutes

Observation ID in Form

GG0175D7

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15 minutes - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94989-1 Wheels across a street

Observation ID in Form

GG0175E7

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95025-3 Manual Wheelchair.Most Dependent

Observation ID in Form

GG0175_8

Fully-Specified Name

Component
FASI v1.0 - Manual wheelchair - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94959-4 Wheel 50 feet with two turns

Observation ID in Form

GG0175B8

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0175E

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94960-2 Wheels 150 feet

Observation ID in Form

GG0175C8

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94961-0 Wheels for 15M

Observation ID in Form

GG0175D8

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15M - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94962-8 Wheels across a street

Observation ID in Form

GG0175E8

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95022-0 Does the person use a motorized wheelchair and/or scooter?

Observation ID in Form

GG0175F

Skip Logic

If 0, Skip to GG0185. If 1, Continue to GG0175G.

Fully-Specified Name

Component
Motorized wheelchair &or scooter use
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95027-9 Motorized Wheelchair/Scooter.Usual

Observation ID in Form

GG0175_7

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's wheelchair mobility performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Motorized wheelchair &or scooter - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94992-5 Wheel 50 feet with two turns

Observation ID in Form

GG0175G7

Skip Logic

If usual and most dependent performance are coded 07, 11,or 90, skip to GG0175J.

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94991-7 Wheels 150 feet

Observation ID in Form

GG0175H7

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94990-9 Wheels for 15 minutes

Observation ID in Form

GG0175I7

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15 minutes - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94989-1 Wheels across a street

Observation ID in Form

GG0175J7

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95026-1 Motorized Wheelchair/Scooter.Most Dependent

Observation ID in Form

GG0175_8

Fully-Specified Name

Component
FASI v1.0 - Motorized wheelchair &or scooter - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94959-4 Wheel 50 feet with two turns

Observation ID in Form

GG0175G8

Skip Logic

If usual and most dependent performance are coded 07, 11,or 90, skip to GG0175J.

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94960-2 Wheels 150 feet

Observation ID in Form

GG0175H8

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94961-0 Wheels for 15M

Observation ID in Form

GG0175I8

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15M - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94962-8 Wheels across a street

Observation ID in Form

GG0175J8

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort