99170-3
Health Conditions
Active
106664-6 Death is Imminent
Observation ID in Form
J0050
Form Context
At the time of this assessment and based on your clinical assessment, does the patient appear to have a life expectancy of 3 days or less?
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Death is Imminent
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Death is Imminent during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106663-8 Pain Screening
Observation ID in Form
J0900
Fully-Specified Name
- Component
- Pain Screening
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
Pain Screening during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
106665-3 Was the patient screened for pain?
Observation ID in Form
J0900A
Skip Logic
If 0, Skip to J0905, Pain Active Problem
Fully-Specified Name
- Component
- Was the patient screened for pain
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Was the patient screened for pain during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106666-1 Date of first screening for pain
Observation ID in Form
J0900B
Fully-Specified Name
- Component
- Date of first screening for pain
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Date of first screening for pain during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
106667-9 The patient’s pain severity was:
Observation ID in Form
J0900C
Fully-Specified Name
- Component
- Patient's pain severity
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Patient's pain severity during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6958-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) | 0 | LA137-2 | |
| Mild | 1 | LA6752-5 | |
| Moderate Copyright http://snomed.info/sct ID:6736007 Moderate (severity modifier) (qualifier value) | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Pain not rated | 9 | LA34607-4 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106669-5 Type of standardized pain tool used:
Observation ID in Form
J0900D
Fully-Specified Name
- Component
- Type of standardized pain tool used
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Nom
- Method
- CMS Assessment
Long Common Name
Type of standardized pain tool used during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6959-2
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Numeric | 1 | LA34570-4 | |
| Verbal descriptor | 2 | LA34608-2 | |
| Patient visual | 3 | LA34609-0 | |
| Staff observation | 4 | LA34610-8 | |
| No standardized tool used | 9 | LA34611-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
106670-3 Pain Active Problem. Is pain an active problem for the patient?
Observation ID in Form
J0905
Skip Logic
If 0, Skip to J2030, Screening for Shortness of Breath
Fully-Specified Name
- Component
- Pain Active Problem
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Pain Active Problem during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106671-1 Comprehensive Pain Assessment
Observation ID in Form
J0910
Fully-Specified Name
- Component
- Comprehensive Pain Assessment
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
Comprehensive Pain Assessment during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
106668-7 Was a comprehensive pain assessment done
Observation ID in Form
J0910A
Skip Logic
If 0, Skip to J2030, Screening for Shortness of Breath
Fully-Specified Name
- Component
- Was a comprehensive pain assessment done
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Was a comprehensive pain assessment done during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106672-9 Date of comprehensive pain assessment
Observation ID in Form
J0910B
Fully-Specified Name
- Component
- Date of comprehensive pain assessment
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Date of comprehensive pain assessment during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
106673-7 Comprehensive pain assessment included:
Observation ID in Form
J0910C
Fully-Specified Name
- Component
- Comprehensive pain assessment included
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Nom
- Method
- CMS Assessment
Long Common Name
Comprehensive pain assessment included during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6960-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Location | 1 | LA34614-0 | |
| Severity | 2 | LA34615-7 | |
| Character | 3 | LA34616-5 | |
| Duration | 4 | LA34617-3 | |
| Frequency | 5 | LA34619-9 | |
| What relieves/worsens pain | 6 | LA34620-7 | |
| Effect on function or quality of life | 7 | LA34621-5 | |
| None of the above_ | 9 | LA34624-9 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
106674-5 Neuropathic Pain
Observation ID in Form
J0915
Form Context
Does the patient have neuropathic pain (e.g., pain with burning, tingling, pins and needles, hypersensitivity to touch)?
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Neuropathic Pain
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Neuropathic Pain during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106675-2 Screening for Shortness of Breath
Observation ID in Form
J2030
Fully-Specified Name
- Component
- Screening for Shortness of Breath
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
Screening for Shortness of Breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
106676-0 Was the patient screened for shortness of breath?
Observation ID in Form
J2030A
Skip Logic
If 0, Skip to J2050, Symptom Impact Screening
Fully-Specified Name
- Component
- Was the patient screened for shortness of breath
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Was the patient screened for shortness of breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106677-8 Date of first screening for shortness of breath:
Observation ID in Form
J2030B
Fully-Specified Name
- Component
- Date of first screening for shortness of breath
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Date of first screening for shortness of breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
106678-6 Did the screening indicate the patient had shortness of breath?
Observation ID in Form
J2030C
Skip Logic
If 0, Skip to J2050, Symptom Impact Screening
Fully-Specified Name
- Component
- Did the screening indicate the patient had shortness of breath
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Did the screening indicate the patient had shortness of breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106679-4 Treatment for Shortness of Breath
Observation ID in Form
J2040
Fully-Specified Name
- Component
- Treatment for Shortness of Breath
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
Treatment for Shortness of Breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
106680-2 Was treatment for shortness of breath initiated?
Observation ID in Form
J2040A
Skip Logic
If 0 or 1, Skip to J2050, Symptom Impact Screening
Fully-Specified Name
- Component
- Was treatment for shortness of breath initiated
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Was treatment for shortness of breath initiated during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6961-8
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| No, patient declined treatment | 1 | LA34625-6 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 2 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106681-0 Date treatment for shortness of breath initiated:
Observation ID in Form
J2040B
Fully-Specified Name
- Component
- Date treatment for shortness of breath initiated
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Date treatment for shortness of breath initiated during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
106685-1 Symptom Impact Screening
Observation ID in Form
J2050
Fully-Specified Name
- Component
- Symptom Impact Screening
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
Symptom Impact Screening during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106684-4 Was a symptom impact screening completed?
Observation ID in Form
J2050A
Skip Logic
If 0, Skip to M1190, Skin Conditions
Fully-Specified Name
- Component
- Was a symptom impact screening completed
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Was a symptom impact screening completed during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106683-6 Date of symptom impact screening:
Observation ID in Form
J2050B
Fully-Specified Name
- Component
- Date of symptom impact screening
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Date of symptom impact screening during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
106682-8 Symptom Impact
Observation ID in Form
J2051
Form Context
Over the past 2 days, how has the patient been affected by each of the following symptoms? Base this on your clinical assessment (including input from patient and/or caregiver). Symptoms may impact multiple patient activities including, but not limited to, sleep, concentration, day to day activities, or ability to interact with others.
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Symptom Impact
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
Symptom Impact during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106688-5 Pain
Observation ID in Form
J2051A
Fully-Specified Name
- Component
- Symptom Impact - Pain
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Pain during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106689-3 Shortness of breath
Observation ID in Form
J2051B
Fully-Specified Name
- Component
- Symptom Impact - Shortness of breath
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Shortness of breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106690-1 Anxiety
Observation ID in Form
J2051C
Fully-Specified Name
- Component
- Symptom Impact - Anxiety
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Anxiety during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106692-7 Nausea
Observation ID in Form
J2051D
Fully-Specified Name
- Component
- Symptom Impact - Nausea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Nausea during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106691-9 Vomiting
Observation ID in Form
J2051E
Fully-Specified Name
- Component
- Symptom Impact - Vomiting
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Vomiting during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106693-5 Diarrhea
Observation ID in Form
J2051F
Fully-Specified Name
- Component
- Symptom Impact - Diarrhea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Diarrhea during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106694-3 Constipation
Observation ID in Form
J2051G
Fully-Specified Name
- Component
- Symptom Impact - Constipation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Constipation during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106695-0 Agitation
Observation ID in Form
J2051H
Fully-Specified Name
- Component
- Symptom Impact - Agitation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Agitation during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106704-0 Symptom Follow-up Visit (SFV)
Observation ID in Form
J2052
Type of Entry
Header section - not a question [H]
Skip Logic
(complete only if any response to J2051 Symptom Impact = 2. Moderate or 3. Severe)
Form Context
An in-person Symptom Follow-up Visit (SFV) should occur within 2 calendar days as a follow-up for any moderate or severe pain or non-pain symptom identified during Symptom Impact assessment at Admission or HOPE Update Visit (HUV).
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Symptom Follow-up Visit
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
Symptom Follow-up Visit during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106705-7 Was an in-person SFV completed?
Observation ID in Form
J2052A
Skip Logic
If 0, Skip to J2052C, Reason SFV Not Completed.
Fully-Specified Name
- Component
- Was an in-person SFV completed
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Was an in-person SFV completed during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL251-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
106706-5 Date of in-person SFV
Observation ID in Form
J2052B
Skip Logic
Complete and skip to J2053, SFV Symptom Impact.
Fully-Specified Name
- Component
- Date of in-person SFV
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Date of in-person SFV during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
106707-3 Reason SFV Not Completed
Observation ID in Form
J2052C
Skip Logic
Skip to M1190, Skin Conditions.
Fully-Specified Name
- Component
- Reason SFV Not Completed
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Reason SFV Not Completed during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6963-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Patient and/or caregiver declined an in-person visit. | 1 | LA34629-8 | |
| Patient unavailable (e.g., in ED, hospital, travel outside of service area, expired). | 2 | LA34630-6 | |
| Attempts to contact patient and/or caregiver were unsuccessful. | 3 | LA34631-4 | |
| None of the above | 9 | LA9-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106708-1 SFV Symptom Impact
Observation ID in Form
J2053
Type of Entry
Header section - not a question [H]
Form Context
Since the last Symptom Impact assessment was completed, how has the patient been affected by each of the following symptoms? Base this on your clinical assessment (including input from patient and/or caregiver). Symptoms may impact multiple patient activities including, but not limited to, sleep, concentration, day to day activities, or ability to interact with others.
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- SFV Symptom Impact
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact during assessment period [CMS Assessment]
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.81 (PANEL)
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106703-2 Pain
Observation ID in Form
J2053A
Fully-Specified Name
- Component
- SFV Symptom Impact - Pain
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Pain during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106702-4 Shortness of breath
Observation ID in Form
J2053B
Fully-Specified Name
- Component
- SFV Symptom Impact - Shortness of breath
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Shortness of breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106701-6 Anxiety
Observation ID in Form
J2053C
Fully-Specified Name
- Component
- SFV Symptom Impact - Anxiety
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Anxiety during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106700-8 Nausea
Observation ID in Form
J2053D
Fully-Specified Name
- Component
- SFV Symptom Impact - Nausea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Nausea during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106699-2 Vomiting
Observation ID in Form
J2053E
Fully-Specified Name
- Component
- SFV Symptom Impact - Vomiting
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Vomiting during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106698-4 Diarrhea
Observation ID in Form
J2053F
Fully-Specified Name
- Component
- SFV Symptom Impact - Diarrhea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Diarrhea during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106697-6 Constipation
Observation ID in Form
J2053G
Fully-Specified Name
- Component
- SFV Symptom Impact - Constipation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Constipation during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106696-8 Agitation
Observation ID in Form
J2053H
Fully-Specified Name
- Component
- SFV Symptom Impact - Agitation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV Symptom Impact - Agitation during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |