LOINC
Version 2.72

99178-6Outcome 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
IndentIndent46500-5 Discipline of Person Completing Assessment
IndentIndent46501-3 Date Assessment Completed {mm/dd/yyyy}
IndentIndent57200-8 This Assessment is Currently Being Completed for the Following Reason
IndentIndent46582-3 Discharge/Transfer/Death Date {mm/dd/yyyy}
IndentIndent93030-5 Transportation. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? 1..2
IndentIndent57276-8 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)?
IndentIndent57277-6 Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? 1..3
IndentIndent46578-1 To which Inpatient Facility has the patient been admitted?
IndentIndent55128-3 Discharge disposition: Where is the patient after discharge from your agency? (Choose only one answer.)
IndentIndent93182-4 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?
IndentIndent93184-0 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
IndentIndent93181-6 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?
IndentIndent93183-2 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
IndentIndent93157-6 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
IndentIndent46589-8 Cognitive Functioning
IndentIndent58104-1 When Confused
IndentIndent86495-9 When Anxious
IndentIndent54605-1 Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
IndentIndent52491-8 Brief Interview for Mental Status
IndentIndentIndent52731-7 Repetition of Three Words
IndentIndentIndent54510-3 Temporal Orientation (Orientation to year, month, and day)
IndentIndentIndentIndent52732-5 Able to report correct year
IndentIndentIndentIndent52733-3 Able to report correct month
IndentIndentIndentIndent54609-3 Able to report correct day of the week
IndentIndentIndent52493-4 Recall
IndentIndentIndentIndent52735-8 Able to recall "sock"
IndentIndentIndentIndent52736-6 Able to recall "blue"
IndentIndentIndentIndent52737-4 Able to recall "bed"
IndentIndentIndent54614-3 BIMS Summary Score {score}
IndentIndent95816-5 Signs and Symptoms of Delirium (from CAM)
IndentIndentIndent95813-2 Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline?
IndentIndentIndent95812-4 Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?
IndentIndentIndent95814-0 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)?
IndentIndentIndent95815-7 Altered level of consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria?
Indent93170-9 Mood
IndentIndent54635-8 Patient Mood Interview (PHQ-2 to 9)
IndentIndentIndent86843-0 Symptom Presence
IndentIndentIndentIndent54636-6 Little interest or pleasure in doing things
IndentIndentIndentIndent54638-2 Feeling down, depressed or hopeless
IndentIndentIndentIndent54640-8 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54642-4 Feeling tired or having little energy
IndentIndentIndentIndent54644-0 Poor appetite or overeating
IndentIndentIndentIndent54646-5 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
IndentIndentIndentIndent54648-1 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54650-7 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
IndentIndentIndentIndent54652-3 Thoughts that you would be better off dead, or of hurting yourself in some way
IndentIndentIndent86844-8 Symptom Frequency
IndentIndentIndentIndent54637-4 Little interest or pleasure in doing things
IndentIndentIndentIndent54639-0 Feeling down, depressed or hopeless
IndentIndentIndentIndent54641-6 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54643-2 Feeling tired or having little energy
IndentIndentIndentIndent54645-7 Poor appetite or overeating
IndentIndentIndentIndent54647-3 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
IndentIndentIndentIndent54649-9 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54651-5 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
IndentIndentIndentIndent54653-1 Thoughts that you would be better off dead, or of hurting yourself in some way
IndentIndent54654-9 Total Severity Score {score}
IndentIndent93159-2 Social Isolation. How often do you feel lonely or isolated from those around you?
Indent99144-8 Behavior
IndentIndent46473-5 Cognitive, Behavorial, and Psychiatric Symptoms that are demonstrated at least once a week (reported or observed)
IndentIndent46592-2 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
IndentIndent88468-4 Types and Sources of Assistance
IndentIndentIndent57260-2 ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding)
IndentIndentIndent57262-8 Medication administration (for example, oral, inhaled or injectable)
IndentIndentIndent57263-6 Medical procedures/treatments (for example, changing wound dressing, home exercise program)
IndentIndentIndent57265-1 Supervision and safety (for example, due to cognitive impairment)
Indent99148-9 Functional Status
IndentIndent46595-5 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).
IndentIndent46597-1 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.
IndentIndent46599-7 Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.
IndentIndent57243-8 Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
IndentIndent57244-6 Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
IndentIndent57245-3 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.
IndentIndent57246-1 Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
IndentIndent57247-9 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
IndentIndent89475-8 Self-Care - Discharge Performance
IndentIndentIndent95019-6 Eating
IndentIndentIndent95018-8 Oral hygiene
IndentIndentIndent95017-0 Toileting hygiene
IndentIndentIndent95015-4 Shower/bathe self
IndentIndentIndent95014-7 Upper body dressing
IndentIndentIndent95013-9 Lower body dressing
IndentIndentIndent95012-1 Putting on/taking off footwear
IndentIndent89474-1 Mobility - Discharge Performance
IndentIndentIndent95011-3 Roll left and right
IndentIndentIndent95010-5 Sit to lying
IndentIndentIndent95009-7 Lying to sitting on side of bed
IndentIndentIndent95008-9 Sit to stand
IndentIndentIndent95007-1 Chair/bed-to-chair transfer
IndentIndentIndent95006-3 Toilet transfer
IndentIndentIndent95005-5 Car transfer
IndentIndentIndent95004-8 Walk 10 feet
IndentIndentIndent95003-0 Walk 50 feet with two turns
IndentIndentIndent95002-2 Walk 150 feet
IndentIndentIndent95001-4 Walking 10 feet on uneven surfaces
IndentIndentIndent95000-6 1 step (curb)
IndentIndentIndent94999-0 4 steps
IndentIndentIndent94998-2 12 steps
IndentIndentIndent94997-4 Picking up object
IndentIndentIndent95738-1 Does the patient use a wheelchair and/or scooter?
IndentIndentIndent94992-5 Wheel 50 feet with two turns
IndentIndentIndent95739-9 Indicate the type of wheelchair or scooter used
IndentIndentIndent94991-7 Wheel 150 feet
IndentIndentIndent95739-9 Indicate the type of wheelchair or scooter used
Indent88497-3 Bladder and Bowel
IndentIndent46552-6 Has this patient been treated for a Urinary Tract Infection in the past 14 days?
IndentIndent46587-2 Bowel Incontinence Frequency
Indent99170-3 Health Conditions
IndentIndent93156-8 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?
IndentIndent93160-0 Pain Interference with Therapy Activities. Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?
IndentIndent93158-4 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?
IndentIndent83280-8 Any Falls Since SOC/ROC - whichever is most recent. Has the patient had any falls since SOC/ROC, whichever is more recent?
IndentIndent54854-5 Number of Falls Since SOC/ROC, whichever is more recent
IndentIndentIndent54855-2 No injury
IndentIndentIndent54856-0 Injury (except major)
IndentIndentIndent54857-8 Major injury
IndentIndent57237-0 When is the patient dyspneic or noticeably Short of Breath?
Indent99188-5 Swallowing And Or Nutritional Status
IndentIndent93178-2 Nutritional Approaches - Last 7 days. Check all of the nutritional approaches that were received in the last 7 days. 1..4
IndentIndent93178-2 Nutritional Approaches - At Discharge. Check all of the following nutritional approaches that apply at discharge. 1..4
IndentIndent57248-7 Feeding or Eating: Current ability to feed self meals and snacks safely.
Indent99189-3 Skin Conditions
IndentIndent85918-1 Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable?
IndentIndent57222-2 The Oldest Stage 2 pressure ulcer that is present at discharge
IndentIndent88508-7 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
IndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndent54886-7 Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent54887-5 Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54890-9 Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent54893-3 Number of unstageable pressure ulcers/injuries due to non-removable dressing/device {#}
IndentIndentIndent54894-1 Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndent54947-7 Number of these unstageable pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent54950-1 Number of unstageable pressure injuries presenting as deep tissue injury {#}
IndentIndentIndent54951-9 Number of these unstageable pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndent57231-3 Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable
IndentIndent57232-1 Does this patient have a Stasis Ulcer?
IndentIndent57234-7 Status of Most Problematic Stasis Ulcer that is Observable
IndentIndent57235-4 Does this patient have a Surgical Wound?
IndentIndent57236-2 Status of Most Problematic Surgical Wound that is Observable
Indent99191-9 Medications
IndentIndent93155-0 High-Risk Drug Classes: Use and Indication
IndentIndentIndent93153-5 Is taking. Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes 1..6
IndentIndentIndent93154-3 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
IndentIndent57256-0 Medication Intervention
IndentIndent57285-9 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
IndentIndent93185-7 Special Treatments, Procedures, and Programs - At Discharge. Check all of the following treatments, procedures, and programs that apply at discharge.
IndentIndent85915-7 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?
IndentIndent57208-1 Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season
Indent99177-8 Participation in Assessment and Goal Setting
IndentIndent99315-4 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?
IndentIndentIndent57271-9 Falls prevention interventions
IndentIndentIndent57272-7 Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment
IndentIndentIndent57273-5 Intervention(s) to monitor and mitigate pain
IndentIndentIndent57274-3 Intervention(s) to prevent pressure ulcers
IndentIndentIndent57275-0 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 2.72
Order vs. Observation
Order
Panel Type
Panel

LOINC FHIR® API Example - CodeSystem and Questionnaire Requests Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=99178-6 https://fhir.loinc.org/Questionnaire/?url=http://loinc.org/q/99178-6