104608-5
MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
Active
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 104608-5 | MDS v3.0 - RAI v1.19.11 - Interim Payment Assessment (IPA) item set | |||
| Indent101258-2 | Identification Information | |||
| Indent Indent58198-3 | Type of Record | |||
| Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent85632-8 | Type of Provider | |||
| Indent Indent90489-6 | Type of Assessment | |||
| Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent45397-7 | Medicare Number | |||
| Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent46098-0 | Gender | |||
| Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent69854-8 | Ethnicity | 1..4 | ||
| Indent Indent103708-4 | Race | 1..14 | ||
| Indent Indent93186-5 | Language | |||
| Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent45404-1 | Marital Status | |||
| Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent54593-9 | Assessment Reference Dat | {mm/dd/yyyy} | ||
| Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent101259-0 | Hearing, Speech, and Vision | |||
| Indent Indent54597-0 | Comatose | |||
| Indent Indent95737-3 | Makes Self Understood | |||
| Indent101260-8 | Cognitive Patterns | |||
| Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted? | |||
| Indent Indent96908-9 | Staff Assessment for Mental Status | |||
| Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent101261-6 | Mood | |||
| Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent54635-8 | Resident 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 Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent101262-4 | Behavior | |||
| Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent54692-9 | Rejection of Care - Presence & Frequency | d/(7.d) | ||
| Indent Indent54693-7 | Wandering - Presence & Frequency | d/(7.d) | ||
| Indent101267-3 | Functional Abilities - OBRA &or Interim | |||
| Indent Indent101430-7 | Self-Care - OBRA/Interim Performance | |||
| Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent101432-3 | Mobility - OBRA/Interim Performance | |||
| Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent85927-2 | Lying to sitting on side of bed | |||
| Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent90507-5 | Bladder and Bowel | |||
| Indent Indent86624-4 | Appliances | 1..2 | ||
| Indent Indent54769-5 | Urinary Toileting Program | |||
| Indent Indent88695-2 | Bowel Toileting Program | |||
| Indent90485-4 | Active Diagnoses | |||
| Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent96095-5 | Indicate the resident's primary medical condition category | |||
| Indent Indent52797-8 | ICD Code | |||
| Indent90488-8 | Health Conditions | |||
| Indent Indent86889-3 | Other Health Conditions | |||
| Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..1 | ||
| Indent Indent Indent86676-4 | Problem Conditions | 1..2 | ||
| Indent Indent90542-2 | Recent Surgery Requiring Active SNF Care | |||
| Indent Indent90745-1 | Surgical Procedures | |||
| Indent90509-1 | Swallowing/Nutritional Status | |||
| Indent Indent86677-2 | Swallowing Disorder | 1..4 | ||
| Indent Indent54863-6 | Weight Loss | |||
| Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..2 | ||
| Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..3 | ||
| Indent Indent90543-0 | Percent Intake by Artificial Route | |||
| Indent Indent Indent86681-4 | Proportion of total calories the resident received through parenteral or tube feeding. While a Resident | |||
| Indent Indent Indent86687-1 | Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days | |||
| Indent Indent Indent86683-0 | Average fluid intake per day by IV or tube feeding. While a Resident | mL/d;L/d | ||
| Indent Indent Indent86684-8 | Average fluid intake per day by IV or tube feeding. During Entire 7 Days | mL/d;L/d | ||
| Indent89051-7 | Skin Conditions | |||
| Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent86892-7 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent54970-9 | Number of Venous and Arterial Ulcers | {#} | ||
| Indent Indent88696-0 | Other Ulcers, Wounds and Skin Problems | 1..6 | ||
| Indent Indent86748-1 | Skin and Ulcer/Injury Treatments | 1..9 | ||
| Indent90513-3 | Medications | |||
| Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent58127-2 | Insulin injections | d/(7.d) | ||
| Indent Indent Indent58128-0 | Orders for insulin | d/(7.d) | ||
| Indent101614-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent86761-4 | Special Treatments, Procedures, and Programs - While a Resident | 1..10 | ||
| Indent Indent55024-4 | Therapies | |||
| Indent Indent Indent58141-3 | Respiratory Therapy | |||
| Indent Indent Indent Indent45766-3 | Respiratory Therapy - Days | d/(7.d) | ||
| Indent Indent Indent86773-9 | Restorative Nursing Programs | |||
| Indent Indent Indent Indent86774-7 | Technique. Range of motion (passive) | d/(7.d) | ||
| Indent Indent Indent Indent86775-4 | Technique. Range of motion (active) | d/(7.d) | ||
| Indent Indent Indent Indent86776-2 | Technique. Splint or brace assistance | d/(7.d) | ||
| Indent Indent Indent Indent86777-0 | Training and Skill Practice In: Bed mobility | d/(7.d) | ||
| Indent Indent Indent Indent86778-8 | Training and Skill Practice In: Transfer | d/(7.d) | ||
| Indent Indent Indent Indent86779-6 | Training and Skill Practice In: Walking | d/(7.d) | ||
| Indent Indent Indent Indent86780-4 | Training and Skill Practice In: Dressing and/or grooming | d/(7.d) | ||
| Indent Indent Indent Indent86781-2 | Training and Skill Practice In: Eating and/or swallowing | d/(7.d) | ||
| Indent Indent Indent Indent86782-0 | Training and Skill Practice In: Amputation/prostheses care | d/(7.d) | ||
| Indent Indent Indent Indent86783-8 | Training and Skill Practice In: Communication | d/(7.d) | ||
| Indent101279-8 | Correction Request | |||
| Indent Indent85632-8 | Type of Provider | |||
| Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent45394-4 | Last name | |||
| Indent Indent46098-0 | Gender | |||
| Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent45396-9 | Social Security Number | |||
| Indent Indent90492-0 | Type of Assessment | |||
| Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent101280-6 | Assessment Administration | |||
| Indent Indent90498-7 | Medicare Part A Billing | |||
| Indent Indent Indent55065-7 | Medicare Part A HIPPS code | |||
| Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} |
Fully-Specified Name
- Component
- MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.78
- Last Updated
- Version 2.78 (ADD)
- Order vs. Observation
- Order
- Panel Type
- Panel
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