99130-7
Outcome and assessment information set (OASIS) form - version E during assessment period [CMS Assessment]
Active
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 99130-7 | Outcome and assessment information set (OASIS) form - version E during assessment period [CMS Assessment] | |||
| Indent99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] | |||
| Indent Indent99132-3 | Administrative Information | |||
| Indent Indent Indent68468-8 | National Provider Identifier (NPI) for the attending physician who has signed the plan of care | |||
| Indent Indent Indent69417-4 | CMS Certification Number | |||
| Indent Indent Indent46494-1 | Branch State | |||
| Indent Indent Indent46495-8 | Branch ID Number | |||
| Indent Indent Indent46496-6 | Patient ID Number | |||
| Indent Indent Indent54503-8 | Patient Name | |||
| Indent Indent Indent Indent45392-8 | (First) | |||
| Indent Indent Indent Indent45393-6 | (MI) | |||
| Indent Indent Indent Indent45394-4 | (Last) | |||
| Indent Indent Indent Indent45395-1 | (Suffix) | |||
| Indent Indent Indent46499-0 | Patient State of Residence | |||
| Indent Indent Indent45401-7 | Patient ZIP Code | |||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent45397-7 | Medicare Number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity: Are you of Hispanic, Latino/a, or Spanish origin? | |||
| Indent Indent Indent103708-4 | Race: What is your race? | |||
| Indent Indent Indent57199-2 | Current Payment Sources for Home Care | 1..11 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent46497-4 | Start of Care Date | {mm/dd/yyyy} | ||
| Indent Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent Indent57201-6 | Date of Physician-ordered Start of Care (Resumption of Care) | {mm/dd/yyyy} | ||
| Indent Indent Indent57202-4 | Date of Referral | {mm/dd/yyyy} | ||
| Indent Indent Indent57203-2 | Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes? | |||
| Indent Indent Indent101351-5 | Transportation | |||
| Indent Indent Indent57204-0 | From which of the following Inpatient Facilities was the patient discharged within the past 14 days? | 1..7 | ||
| Indent Indent Indent86470-2 | Inpatient Discharge Date (most recent) | {mm/dd/yyyy} | ||
| Indent Indent99138-0 | Hearing, Speech, and Vision | |||
| Indent Indent Indent95744-9 | Hearing | |||
| Indent Indent Indent95745-6 | Vision | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent99140-6 | Cognitive Patterns | |||
| Indent Indent Indent46589-8 | Cognitive Functioning | |||
| Indent Indent Indent58104-1 | When Confused | |||
| Indent Indent Indent86495-9 | When Anxious | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline? | |||
| Indent Indent Indent Indent95812-4 | Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? | |||
| Indent Indent Indent Indent95814-0 | Disorganized thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? | |||
| Indent Indent Indent Indent95815-7 | Altered level of consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? | |||
| Indent Indent93170-9 | Mood | |||
| Indent Indent Indent54635-8 | Patient Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent99144-8 | Behavior | |||
| Indent Indent Indent46473-5 | Cognitive, Behavorial, and Psychiatric Symptoms that are demonstrated at least once a week (reported or observed) | |||
| Indent Indent Indent46592-2 | Frequency of Disruptive Behavior Symptoms (reported or observed): Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety. | |||
| Indent Indent99147-1 | Preferences for Customary Routine Activities | |||
| Indent Indent Indent85950-4 | Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? | |||
| Indent Indent Indent88465-0 | Types and Sources of Assistance | |||
| Indent Indent Indent Indent57265-1 | Supervision and safety (for example, due to cognitive impairment) | |||
| Indent Indent99148-9 | Functional Status | |||
| Indent Indent Indent46595-5 | Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). | |||
| Indent Indent Indent46597-1 | Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. | |||
| Indent Indent Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
| Indent Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
| Indent Indent Indent57244-6 | Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. | |||
| Indent Indent Indent57245-3 | Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment. | |||
| Indent Indent Indent57246-1 | Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. | |||
| Indent Indent Indent57247-9 | Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. | |||
| Indent Indent89572-2 | Functional Abilities and Goals | |||
| Indent Indent Indent83239-4 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent Indent89479-0 | Self-Care - SOC/ROC Performance | |||
| Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent89478-2 | Self-Care - Discharge Goal | |||
| Indent Indent Indent Indent89404-8 | Oral hygiene - functional goal during assessment period [CMS Assessment] | |||
| Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent89477-4 | Mobility - SOC/ROC Performance | |||
| Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent95738-1 | Does the patient use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent89476-6 | Mobility - Discharge Goal | |||
| Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent85927-2 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent89420-4 | 1 step (curb) | |||
| Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent89375-0 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent89377-6 | Wheel 150 feet | |||
| Indent Indent88496-5 | Bladder and Bowel | |||
| Indent Indent Indent46552-6 | Has this patient been treated for a Urinary Tract Infection in the past 14 days? | |||
| Indent Indent Indent46553-4 | Urinary Incontinence or Urinary Catheter Presence | |||
| Indent Indent Indent46587-2 | Bowel Incontinence Frequency | |||
| Indent Indent Indent86471-0 | Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen? | |||
| Indent Indent99146-3 | Active Diagnoses | |||
| Indent Indent Indent83243-6 | Active Diagnoses-Comorbidities and Co-existing Conditions | 1..2 | ||
| Indent Indent Indent88488-2 | Primary Diagnosis & Other Diagnoses | |||
| Indent Indent Indent Indent88489-0 | Primary Diagnosis | |||
| Indent Indent Indent Indent Indent86255-7 | Primary Diagnosis: ICD-10-code | |||
| Indent Indent Indent Indent Indent85920-7 | Primary Diagnosis Symptom Control Rating | |||
| Indent Indent Indent Indent88490-8 | Other Diagnoses | |||
| Indent Indent Indent Indent Indent81885-6 | Other Diagnoses: ICD-10-CM | |||
| Indent Indent Indent Indent Indent85920-7 | Other Diagnoses Symptom Control Rating | |||
| Indent Indent99142-2 | Health Conditions | |||
| Indent Indent Indent57319-6 | Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? | 1..9 | ||
| Indent Indent Indent93156-8 | Pain Effect on Sleep. Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? | |||
| Indent Indent Indent93160-0 | Pain Interference with Therapy Activities. Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? | |||
| Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? | |||
| Indent Indent Indent57237-0 | When is the patient dyspneic or noticeably Short of Breath? | |||
| Indent Indent99152-1 | Swallowing/Nutritional Status | |||
| Indent Indent Indent54567-3 | Height and Weight: - While measuring, if the number is X.1-X.4 round down; X.5 or greater round up | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent93178-2 | Nutritional Approaches - On Admission. Check all of the following nutritional approaches that apply on admission | 1..4 | ||
| Indent Indent Indent57248-7 | Feeding or Eating: Current ability to feed self meals and snacks safely | |||
| Indent Indent88463-5 | Skin Conditions | |||
| Indent Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? | |||
| Indent Indent Indent88494-0 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent46536-9 | Current Number of Stage 1 Pressure Injuries | {#} | ||
| Indent Indent Indent57231-3 | Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable | |||
| Indent Indent Indent57232-1 | Does this patient have a Stasis Ulcer? | |||
| Indent Indent Indent57233-9 | Current Number of Stasis Ulcer(s) that are Observable | {#} | ||
| Indent Indent Indent57234-7 | Status of Most Problematic Stasis Ulcer that is Observable | |||
| Indent Indent Indent57235-4 | Does this patient have a Surgical Wound? | |||
| Indent Indent Indent57236-2 | Status of Most Problematic Surgical Wound that is Observable | |||
| Indent Indent99151-3 | Medications | |||
| Indent Indent Indent93155-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking. Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes | 1..6 | ||
| Indent Indent Indent Indent93154-3 | Indication noted. If column 1 [Is Taking] is checked, check if there is an indication noted for all medications in the drug class | 0..6 | ||
| Indent Indent Indent57255-2 | Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? | |||
| Indent Indent Indent57281-8 | Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? | |||
| Indent Indent Indent57257-8 | Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur? | |||
| Indent Indent Indent57285-9 | Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals | |||
| Indent Indent Indent57284-2 | Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals | |||
| Indent Indent99143-0 | Special Treatment, Procedures, and Programs | |||
| Indent Indent Indent83252-7 | Special Treatments, Procedures, and Programs - On Admission. Check all of the following treatments, procedures, and programs that apply on admission | |||
| Indent Indent Indent57268-5 | Therapy need: Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined) | {#} | ||
| Indent99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] | |||
| Indent Indent99161-2 | Administrative Information | |||
| Indent Indent Indent46498-2 | Resumption of Care Date | {mm/dd/yyyy} | ||
| Indent Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent Indent57201-6 | Date of Physician-ordered Start of Care (Resumption of Care) | {mm/dd/yyyy} | ||
| Indent Indent Indent57202-4 | Date of Referral | {mm/dd/yyyy} | ||
| Indent Indent Indent57203-2 | Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes? | |||
| Indent Indent Indent101351-5 | Transportation | |||
| Indent Indent Indent57204-0 | From which of the following Inpatient Facilities was the patient discharged within the past 14 days? | 1..7 | ||
| Indent Indent Indent86470-2 | Inpatient Discharge Date (most recent) | {mm/dd/yyyy} | ||
| Indent Indent93166-7 | Hearing, Speech, and Vision | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent99140-6 | Cognitive Patterns | |||
| Indent Indent Indent46589-8 | Cognitive Functioning | |||
| Indent Indent Indent58104-1 | When Confused | |||
| Indent Indent Indent86495-9 | When Anxious | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline? | |||
| Indent Indent Indent Indent95812-4 | Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? | |||
| Indent Indent Indent Indent95814-0 | Disorganized thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? | |||
| Indent Indent Indent Indent95815-7 | Altered level of consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? | |||
| Indent Indent93170-9 | Mood | |||
| Indent Indent Indent54635-8 | Patient Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent99144-8 | Behavior | |||
| Indent Indent Indent46473-5 | Cognitive, Behavorial, and Psychiatric Symptoms that are demonstrated at least once a week (reported or observed) | |||
| Indent Indent Indent46592-2 | Frequency of Disruptive Behavior Symptoms (reported or observed): Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety. | |||
| Indent Indent99147-1 | Preferences for Customary Routine Activities | |||
| Indent Indent Indent85950-4 | Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? | |||
| Indent Indent Indent88465-0 | Types and Sources of Assistance | |||
| Indent Indent Indent Indent57265-1 | Supervision and safety (for example, due to cognitive impairment) | |||
| Indent Indent99148-9 | Functional Status | |||
| Indent Indent Indent46595-5 | Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). | |||
| Indent Indent Indent46597-1 | Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. | |||
| Indent Indent Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
| Indent Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
| Indent Indent Indent57244-6 | Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. | |||
| Indent Indent Indent57245-3 | Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment. | |||
| Indent Indent Indent57246-1 | Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. | |||
| Indent Indent Indent57247-9 | Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. | |||
| Indent Indent89572-2 | Functional Abilities and Goals | |||
| Indent Indent Indent83239-4 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent Indent89479-0 | Self-Care - SOC/ROC Performance | |||
| Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent89478-2 | Self-Care - Discharge Goal | |||
| Indent Indent Indent Indent89404-8 | Oral hygiene - functional goal during assessment period [CMS Assessment] | |||
| Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent89477-4 | Mobility - SOC/ROC Performance | |||
| Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent95738-1 | Does the patient use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent89476-6 | Mobility - Discharge Goal | |||
| Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent85927-2 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent89420-4 | 1 step (curb) | |||
| Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent89375-0 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent89377-6 | Wheel 150 feet | |||
| Indent Indent88496-5 | Bladder and Bowel | |||
| Indent Indent Indent46552-6 | Has this patient been treated for a Urinary Tract Infection in the past 14 days? | |||
| Indent Indent Indent46553-4 | Urinary Incontinence or Urinary Catheter Presence | |||
| Indent Indent Indent46587-2 | Bowel Incontinence Frequency | |||
| Indent Indent Indent86471-0 | Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen? | |||
| Indent Indent99169-5 | Active Diagnoses | |||
| Indent Indent Indent83243-6 | Active Diagnoses-Comorbidities and Co-existing Conditions | 1..2 | ||
| Indent Indent Indent88488-2 | Primary Diagnosis & Other Diagnoses | |||
| Indent Indent Indent Indent88489-0 | Primary Diagnosis | |||
| Indent Indent Indent Indent Indent86255-7 | Primary Diagnosis: ICD-10-code | |||
| Indent Indent Indent Indent Indent85920-7 | Primary Diagnosis Symptom Control Rating | |||
| Indent Indent Indent Indent88490-8 | Other Diagnoses | |||
| Indent Indent Indent Indent Indent81885-6 | Other Diagnoses: ICD-10-CM | |||
| Indent Indent Indent Indent Indent85920-7 | Other Diagnoses Symptom Control Rating | |||
| Indent Indent99142-2 | Health Conditions | |||
| Indent Indent Indent57319-6 | Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? | 1..9 | ||
| Indent Indent Indent93156-8 | Pain Effect on Sleep. Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? | |||
| Indent Indent Indent93160-0 | Pain Interference with Therapy Activities. Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? | |||
| Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? | |||
| Indent Indent Indent57237-0 | When is the patient dyspneic or noticeably Short of Breath? | |||
| Indent Indent99171-1 | Swallowing And Or Nutritional Status | |||
| Indent Indent Indent54567-3 | Height and Weight: - While measuring, if the number is X.1-X.4 round down; X.5 or greater round up | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent93178-2 | Nutritional Approaches - On Admission. Check all of the following nutritional approaches that apply on admission | 1..4 | ||
| Indent Indent Indent57248-7 | Feeding or Eating: Current ability to feed self meals and snacks safely | |||
| Indent Indent88463-5 | Skin Conditions | |||
| Indent Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? | |||
| Indent Indent Indent88494-0 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent46536-9 | Current Number of Stage 1 Pressure Injuries | {#} | ||
| Indent Indent Indent57231-3 | Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable | |||
| Indent Indent Indent57232-1 | Does this patient have a Stasis Ulcer? | |||
| Indent Indent Indent57233-9 | Current Number of Stasis Ulcer(s) that are Observable | {#} | ||
| Indent Indent Indent57234-7 | Status of Most Problematic Stasis Ulcer that is Observable | |||
| Indent Indent Indent57235-4 | Does this patient have a Surgical Wound? | |||
| Indent Indent Indent57236-2 | Status of Most Problematic Surgical Wound that is Observable | |||
| Indent Indent99151-3 | Medications | |||
| Indent Indent Indent93155-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking. Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes | 1..6 | ||
| Indent Indent Indent Indent93154-3 | Indication noted. If column 1 [Is Taking] is checked, check if there is an indication noted for all medications in the drug class | 0..6 | ||
| Indent Indent Indent57255-2 | Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? | |||
| Indent Indent Indent57281-8 | Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? | |||
| Indent Indent Indent57257-8 | Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur? | |||
| Indent Indent Indent57285-9 | Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals | |||
| Indent Indent Indent57284-2 | Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals | |||
| Indent Indent99173-7 | Special Treatment, Procedures, and Programs | |||
| Indent Indent Indent83252-7 | Special Treatments, Procedures, and Programs - On Admission. Check all of the following treatments, procedures, and programs that apply on admission | |||
| Indent Indent Indent57268-5 | Therapy need: Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined) | {#} | ||
| Indent99158-8 | Outcome and assessment information set (OASIS) form - version E - Death at Home during assessment period [CMS Assessment] | |||
| Indent Indent99159-6 | Administrative Information | |||
| Indent Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent Indent46582-3 | Discharge/Transfer/Death Date | {mm/dd/yyyy} | ||
| Indent Indent83279-0 | Health Conditions | |||
| Indent Indent Indent83280-8 | Any Falls Since SOC/ROC - whichever is most recent. Has the patient had any falls since SOC/ROC, whichever is more recent? | |||
| Indent Indent Indent54854-5 | Number of Falls Since SOC/ROC, whichever is more recent | |||
| Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent86262-3 | Medications | |||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent99174-5 | Outcome and assessment information set (OASIS) form - version E - Transfer to an Inpatient Facility during assessment period [CMS Assessment] | |||
| Indent Indent99175-2 | Administrative Information | |||
| Indent Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent Indent46582-3 | Discharge/Transfer/Death Date | {mm/dd/yyyy} | ||
| Indent Indent Indent57276-8 | Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)? | |||
| Indent Indent Indent57277-6 | Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? | 1..3 | ||
| Indent Indent Indent46578-1 | To which Inpatient Facility has the patient been admitted? | |||
| Indent Indent Indent99286-7 | Provision of Current Reconciled Medication List to Subsequent Provider at Transfer: At the time of transfer to another provider, did your agency provide the patient’s current reconciled medication list to the subsequent provider? | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider. Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider | 1..5 | ||
| Indent Indent83279-0 | Health Conditions | |||
| Indent Indent Indent83280-8 | Any falls since SOC/ROC. Has the patient had any falls since SOC/ROC, whichever is more recent? Has the patient had any falls since SOC/ROC, whichever is more recent? | |||
| Indent Indent Indent54854-5 | Number of Falls Since SOC/ROC, whichever is more recent | |||
| Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent86262-3 | Medications | |||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent99176-0 | Special Treatment, Procedures, and Programs | |||
| Indent Indent Indent85915-7 | InfluenzaVaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31? | |||
| Indent Indent Indent57208-1 | Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season | |||
| Indent Indent99177-8 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent99315-4 | Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan or care AND implemented? | |||
| Indent Indent Indent Indent57271-9 | Falls prevention interventions | |||
| Indent Indent Indent Indent57272-7 | Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment | |||
| Indent Indent Indent Indent57273-5 | Intervention(s) to monitor and mitigate pain | |||
| Indent Indent Indent Indent57274-3 | Intervention(s) to prevent pressure ulcers | |||
| Indent Indent Indent Indent57275-0 | Pressure ulcer treatment based on principles of moist wound healing | |||
| Indent99153-9 | Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment] | |||
| Indent Indent86245-8 | Administrative Information | |||
| Indent Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent Indent57203-2 | Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes? | |||
| Indent Indent99155-4 | Functional Status | |||
| Indent Indent Indent46595-5 | Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). | |||
| Indent Indent Indent46597-1 | Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. | |||
| Indent Indent Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
| Indent Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
| Indent Indent Indent57244-6 | Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. | |||
| Indent Indent Indent57246-1 | Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. | |||
| Indent Indent Indent57247-9 | Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. | |||
| Indent Indent99154-7 | Functional Abilities and Goals | |||
| Indent Indent Indent99149-7 | Self-Care - Follow-up Performance | |||
| Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent99150-5 | Mobility - Follow-up Perfomance | |||
| Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent83206-3 | Car transfer | |||
| Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent83200-6 | Walk 150 feet | |||
| Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent83192-5 | 12 steps | |||
| Indent Indent Indent Indent95738-1 | Does the patient use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent83235-2 | Wheel 150 feet | |||
| Indent Indent99156-2 | Health Conditions | |||
| Indent Indent Indent57319-6 | Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? | 1..9 | ||
| Indent Indent99157-0 | Skin Conditions | |||
| Indent Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? | |||
| Indent99178-6 | Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment] | |||
| Indent Indent99179-4 | Administrative Information | |||
| Indent Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent Indent46582-3 | Discharge/Transfer/Death Date | {mm/dd/yyyy} | ||
| Indent Indent Indent101351-5 | Transportation | |||
| Indent Indent Indent57276-8 | Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)? | |||
| Indent Indent Indent57277-6 | Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? | 1..3 | ||
| Indent Indent Indent46578-1 | To which Inpatient Facility has the patient been admitted? | |||
| Indent Indent Indent55128-3 | Discharge disposition: Where is the patient after discharge from your agency? (Choose only one answer.) | |||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider. Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider | 1..5 | ||
| Indent Indent Indent93181-6 | Provision of Current Reconciled Medication List to Patient at Discharge | |||
| Indent Indent Indent93183-2 | Route of Current Reconciled Medication List Transmission to Patient. Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver | 1..5 | ||
| Indent Indent93166-7 | Hearing, Speech, and Vision | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent99140-6 | Cognitive Patterns | |||
| Indent Indent Indent46589-8 | Cognitive Functioning | |||
| Indent Indent Indent58104-1 | When Confused | |||
| Indent Indent Indent86495-9 | When Anxious | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline? | |||
| Indent Indent Indent Indent95812-4 | Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? | |||
| Indent Indent Indent Indent95814-0 | Disorganized thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? | |||
| Indent Indent Indent Indent95815-7 | Altered level of consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? | |||
| Indent Indent93170-9 | Mood | |||
| Indent Indent Indent54635-8 | Patient Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent99144-8 | Behavior | |||
| Indent Indent Indent46473-5 | Cognitive, Behavorial, and Psychiatric Symptoms that are demonstrated at least once a week (reported or observed) | |||
| Indent Indent Indent46592-2 | Frequency of Disruptive Behavior Symptoms (reported or observed): Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety. | |||
| Indent Indent88467-6 | Preferences for Customary Routine Activities | |||
| Indent Indent Indent88468-4 | Types and Sources of Assistance | |||
| Indent Indent Indent Indent57260-2 | ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding) | |||
| Indent Indent Indent Indent57262-8 | Medication administration (for example, oral, inhaled or injectable) | |||
| Indent Indent Indent Indent57263-6 | Medical procedures/treatments (for example, changing wound dressing, home exercise program) | |||
| Indent Indent Indent Indent57265-1 | Supervision and safety (for example, due to cognitive impairment) | |||
| Indent Indent99148-9 | Functional Status | |||
| Indent Indent Indent46595-5 | Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). | |||
| Indent Indent Indent46597-1 | Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. | |||
| Indent Indent Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
| Indent Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
| Indent Indent Indent57244-6 | Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. | |||
| Indent Indent Indent57245-3 | Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment. | |||
| Indent Indent Indent57246-1 | Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. | |||
| Indent Indent Indent57247-9 | Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. | |||
| Indent Indent89391-7 | Functional Abilities and Goals | |||
| Indent Indent Indent89475-8 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent89474-1 | Mobility - Discharge Performance | |||
| Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent95738-1 | Does the patient use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent88497-3 | Bladder and Bowel | |||
| Indent Indent Indent46552-6 | Has this patient been treated for a Urinary Tract Infection in the past 14 days? | |||
| Indent Indent Indent46587-2 | Bowel Incontinence Frequency | |||
| Indent Indent99170-3 | Health Conditions | |||
| Indent Indent Indent93156-8 | Pain Effect on Sleep. Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? | |||
| Indent Indent Indent93160-0 | Pain Interference with Therapy Activities. Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? | |||
| Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? | |||
| Indent Indent Indent83280-8 | Any Falls Since SOC/ROC - whichever is most recent. Has the patient had any falls since SOC/ROC, whichever is more recent? | |||
| Indent Indent Indent54854-5 | Number of Falls Since SOC/ROC, whichever is more recent | |||
| Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent Indent57237-0 | When is the patient dyspneic or noticeably Short of Breath? | |||
| Indent Indent99188-5 | Swallowing And Or Nutritional Status | |||
| Indent Indent Indent93178-2 | Nutritional Approaches - Last 7 days. Check all of the nutritional approaches that were received in the last 7 days | 1..4 | ||
| Indent Indent Indent93178-2 | Nutritional Approaches - At Discharge. Check all of the following nutritional approaches that apply at discharge | 1..4 | ||
| Indent Indent Indent57248-7 | Feeding or Eating: Current ability to feed self meals and snacks safely | |||
| Indent Indent99189-3 | Skin Conditions | |||
| Indent Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? | |||
| Indent Indent Indent57222-2 | The Oldest Stage 2 pressure ulcer that is present at discharge | |||
| Indent Indent Indent88508-7 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent57231-3 | Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable | |||
| Indent Indent Indent57232-1 | Does this patient have a Stasis Ulcer? | |||
| Indent Indent Indent57234-7 | Status of Most Problematic Stasis Ulcer that is Observable | |||
| Indent Indent Indent57235-4 | Does this patient have a Surgical Wound? | |||
| Indent Indent Indent57236-2 | Status of Most Problematic Surgical Wound that is Observable | |||
| Indent Indent99191-9 | Medications | |||
| Indent Indent Indent93155-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking. Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes | 1..6 | ||
| Indent Indent Indent Indent93154-3 | Indication noted. If column 1 [Is Taking] is checked, check if there is an indication noted for all medications in the drug class | 0..6 | ||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent Indent57285-9 | Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals | |||
| Indent Indent99190-1 | Special Treatment, Procedures, and Programs | |||
| Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge. Check all of the following treatments, procedures, and programs that apply at discharge | |||
| Indent Indent Indent85915-7 | InfluenzaVaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31? | |||
| Indent Indent Indent57208-1 | Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season | |||
| Indent Indent99177-8 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent99315-4 | Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan or care AND implemented? | |||
| Indent Indent Indent Indent57271-9 | Falls prevention interventions | |||
| Indent Indent Indent Indent57272-7 | Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment | |||
| Indent Indent Indent Indent57273-5 | Intervention(s) to monitor and mitigate pain | |||
| Indent Indent Indent Indent57274-3 | Intervention(s) to prevent pressure ulcers | |||
| Indent Indent Indent Indent57275-0 | Pressure ulcer treatment based on principles of moist wound healing |
Fully-Specified Name
- Component
- Outcome and assessment information set (OASIS) form - version E
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.72
- Last Updated
- Version 2.77 (PANEL)
- 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
- Order
- Panel Type
- Convenience group
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=99130-7 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/99130-7
LOINC Copyright
Copyright © 2025 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://