94850-5
Self-Care.Most Dependent
Active
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 ServicesFully-Specified Name
- Component
- Eating - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Eating - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-Specified Name
- Component
- Oral hygiene - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Oral hygiene - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-Specified Name
- Component
- Toileting hygiene - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Toileting hygiene - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-Specified Name
- Component
- Wash upper body - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Wash upper body - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-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
Long Common Name
Shower/bathe self - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-Specified Name
- Component
- Upper body dressing - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Upper body dressing - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-Specified Name
- Component
- Lower body dressing - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Lower body dressing - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-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
Long Common Name
Putting on and taking off footwear - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [CMS Assessment] |