99178-6
Outcome and assessment information set (OASIS) form - version E - Discharge from Agency [CMS Assessment]
Active
Term Description
This panel should be used for CMS OASIS-E Discharge from Agency assessments performed after January 1, 2023.
Source: Regenstrief LOINC
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 99178-6 | Outcome and assessment information set (OASIS) form - version E - Discharge from Agency [CMS Assessment] | |||
| Indent99179-4 | Administrative Information | |||
| Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent46582-3 | Discharge/Transfer/Death Date | {mm/dd/yyyy} | ||
| Indent Indent101351-5 | Transportation. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? | |||
| 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 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 Indent46578-1 | To which Inpatient Facility has the patient been admitted? | |||
| Indent Indent55128-3 | Discharge disposition: Where is the patient after discharge from your agency? (Choose only one answer.) | |||
| Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge. At the time of discharge to another provider, did your facility provide the patient's current reconciled medication list to the subsequent provider? | |||
| 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 Indent93181-6 | Provision of Current Reconciled Medication List to Patient at Discharge. At the time of discharge, did your facility provide the patient's current reconciled medication list to the patient, family and/or caregiver? | |||
| 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 | ||
| Indent93166-7 | Hearing, Speech, and Vision | |||
| Indent Indent93157-6 | Health Literacy. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? | |||
| Indent99140-6 | Cognitive Patterns | |||
| Indent Indent46589-8 | Cognitive Functioning | |||
| Indent Indent58104-1 | When Confused | |||
| Indent Indent86495-9 | When Anxious | |||
| Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent52491-8 | Brief Interview for Mental Status | |||
| Indent Indent Indent52731-7 | Repetition of Three Words | |||
| Indent Indent Indent54510-3 | Temporal Orientation (Orientation to year, month, and day) | |||
| Indent Indent Indent Indent52732-5 | Able to report correct year | |||
| Indent Indent Indent Indent52733-3 | Able to report correct month | |||
| Indent Indent Indent Indent54609-3 | Able to report correct day of the week | |||
| Indent Indent Indent52493-4 | Recall | |||
| Indent Indent Indent Indent52735-8 | Able to recall "sock" | |||
| Indent Indent Indent Indent52736-6 | Able to recall "blue" | |||
| Indent Indent Indent Indent52737-4 | Able to recall "bed" | |||
| Indent Indent Indent54614-3 | BIMS Summary Score | {score} | ||
| Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM) | |||
| 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 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 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 Indent95815-7 | Altered level of consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? | |||
| Indent93170-9 | Mood | |||
| Indent Indent54635-8 | Patient Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| 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 Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| 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 Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| 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 Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| 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 Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent54654-9 | Total Severity Score | {score} | ||
| Indent Indent93159-2 | Social Isolation. How often do you feel lonely or isolated from those around you? | |||
| Indent99144-8 | Behavior | |||
| Indent Indent46473-5 | Cognitive, Behavorial, and Psychiatric Symptoms that are demonstrated at least once a week (reported or observed) | |||
| 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. | |||
| Indent88467-6 | Preferences for Customary Routine Activities | |||
| Indent Indent88468-4 | Types and Sources of Assistance | |||
| Indent Indent Indent57260-2 | ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding) | |||
| Indent Indent Indent57262-8 | Medication administration (for example, oral, inhaled or injectable) | |||
| Indent Indent Indent57263-6 | Medical procedures/treatments (for example, changing wound dressing, home exercise program) | |||
| Indent Indent Indent57265-1 | Supervision and safety (for example, due to cognitive impairment) | |||
| Indent99148-9 | Functional Status | |||
| 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 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 Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
| Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
| 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 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 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 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. | |||
| Indent89391-7 | Functional Abilities and Goals | |||
| Indent Indent89475-8 | Self-Care - Discharge Performance | |||
| Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent89474-1 | Mobility - Discharge Performance | |||
| Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent95738-1 | Does the patient use a wheelchair and/or scooter? | |||
| Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent88497-3 | Bladder and Bowel | |||
| Indent Indent46552-6 | Has this patient been treated for a Urinary Tract Infection in the past 14 days? | |||
| Indent Indent46587-2 | Bowel Incontinence Frequency | |||
| Indent99170-3 | Health Conditions | |||
| 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 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 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 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 Indent54854-5 | Number of Falls Since SOC/ROC, whichever is more recent | |||
| Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent57237-0 | When is the patient dyspneic or noticeably Short of Breath? | |||
| Indent99188-5 | Swallowing And Or Nutritional Status | |||
| 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 Indent93178-2 | Nutritional Approaches - At Discharge. Check all of the following nutritional approaches that apply at discharge. | 1..4 | ||
| Indent Indent57248-7 | Feeding or Eating: Current ability to feed self meals and snacks safely. | |||
| Indent99189-3 | Skin Conditions | |||
| Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? | |||
| Indent Indent57222-2 | The Oldest Stage 2 pressure ulcer that is present at discharge | |||
| Indent Indent88508-7 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent54946-9 | Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent54951-9 | Number of these unstageable pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent57231-3 | Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable | |||
| Indent Indent57232-1 | Does this patient have a Stasis Ulcer? | |||
| Indent Indent57234-7 | Status of Most Problematic Stasis Ulcer that is Observable | |||
| Indent Indent57235-4 | Does this patient have a Surgical Wound? | |||
| Indent Indent57236-2 | Status of Most Problematic Surgical Wound that is Observable | |||
| Indent99191-9 | Medications | |||
| Indent Indent93155-0 | High-Risk Drug Classes: Use and Indication | |||
| 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 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 Indent57256-0 | Medication Intervention | |||
| 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. | |||
| Indent99190-1 | Special Treatment, Procedures, and Programs | |||
| Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge. Check all of the following treatments, procedures, and programs that apply at discharge. | |||
| 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 Indent57208-1 | Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season | |||
| Indent99177-8 | Participation in Assessment and Goal Setting | |||
| 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 Indent57271-9 | Falls prevention interventions | |||
| Indent Indent Indent57272-7 | Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment | |||
| Indent Indent Indent57273-5 | Intervention(s) to monitor and mitigate pain | |||
| Indent Indent Indent57274-3 | Intervention(s) to prevent pressure ulcers | |||
| 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 - Discharge from Agency
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.72
- Last Updated
- Version 2.74
- Order vs. Observation
- Order
- Panel Type
- Panel
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