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Form Coding Instructions

Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s). Safety and Quality of Performance - If helper assistance is required because patient'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

Form Coding Instructions

(3-day assessment period)

Source: Centers for Medicare & Medicaid Services

89398-2 Roll left and right

Observation ID in Form

GG0170A2

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

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

Long Common Name

Roll left and right - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89394-1 Sit to lying

Observation ID in Form

GG0170B2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Sit to lying - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

85927-2 Lying to sitting on side of bed

Term Description

Expected functional performance for the patient's usual 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.

Observation ID in Form

GG0170C2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Lying to sitting on side of bed - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.63
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
86189-8Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89392-5 Sit to stand

Observation ID in Form

GG0170D2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Sit to stand - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89414-7 Chair/bed-to-chair transfer

Observation ID in Form

GG0170E2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Chair/bed-to-chair transfer - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; 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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89390-9 Toilet transfer

Observation ID in Form

GG0170F2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Toilet transfer - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89385-9 Walk 10 feet

Observation ID in Form

GG0170I2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Walk 10 feet - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89381-8 Walk 50 feet with two turns

Observation ID in Form

GG0170J2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Walk 50 feet with two turns - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89383-4 Walk 150 feet

Observation ID in Form

GG0170K2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Walk 150 feet - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

89375-0 Wheel 50 feet with two turns

Observation ID in Form

GG0170R2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Wheel 50 feet with two turns - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

89377-6 Wheel 150 feet

Observation ID in Form

GG0170S2

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 - functional goal
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Long Common Name

Wheel 150 feet - functional goal during assessment period [CMS Assessment]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.77 (MAJ)
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 LL4681-4

AnswerCodeScoreAnswer ID
Independent - Patient completes the activity by themself with no assistance from a helper.06LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.05LA10073-7
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.04LA28225-3
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.03LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.02LA11759-0
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.01LA27665-1
Patient refused07LA10058-8
Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.09LA28226-1
Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)10LA28227-9
Not attempted due to medical condition or safety concerns88LA26735-3

Member of these Panels

LOINCLong Common Name
89963-3Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
87509-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
90473-0Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90474-8Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90476-3Deprecated MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
93128-7Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
88368-6Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99160-4Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]