52474-4
Skin integrity panel
Discouraged
52475-1 Presence of pressure ulcers
Observation ID in Form
G1-2
Form Coding Instructions
Do not reverse stage
Source: Regenstrief HelpFully-Specified Name
- Component
- Presence of pressure ulcers
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
52573-3 Is this patient at risk of developing pressure ulcers?
Observation ID in Form
G1
Fully-Specified Name
- Component
- Risk of developing pressure ulcers
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Long Common Name
Risk of developing pressure ulcers [CARE]
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Normative Answer List LL723-8
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 | |
| Yes, indicated by clinical judgement | 1 | LA11612-1 | |
| Yes, indicated by high risk by formal assessment (e.g., on Braden or Norton tools) or the patient has a stage I or greater ulcer, a scar over a bony prominence, or a non-removable dressing, device, or cast. | 2 | LA11613-9 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
69338-2 One or more unhealed pressure ulcer(s) at stage 2 or higher
Observation ID in Form
G2
Fully-Specified Name
- Component
- One or more unhealed pressure ulcer(s) at stage 2 or higher - interim, post acute care discharge
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Long Common Name
One or more unhealed pressure ulcer(s) at stage 2 or higher - CARE - interim, PAC discharge [CARE]
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.38
- Last Updated
- Version 2.64 (MIN)
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
52476-9 IF THE PATIENT HAS ONE OR MORE STAGE 2-4 PRESSURE ULCERS, indicate the number of unhealed pressure ulcers at each stage
Term Description
Pressure ulcer at stage 2, stage 3, or stage 4 only:
Form Coding Instructions
CODING: Please specify the number of ulcers at each stage:
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of unhealed pressure ulcers at each stage - at assessment and onset during this service
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
Long Common Name
Number of unhealed pressure ulcers at each stage - at assessment and onset during this service
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
52575-8 Number of pressure ulcers at assessment - stage 2 [CARE]
Term Description
Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (excludes those resulting from skin tears, tape stripping, or incontinence associated dermatitis).
Observation ID in Form
G2a
Form Coding Instructions
If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of pressure ulcers at assessment - stage 2
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52576-6 Number of pressure ulcers at assessment - stage 3 [CARE]
Term Description
Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Observation ID in Form
G2b
Form Coding Instructions
If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of pressure ulcers at assessment - stage 3
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52577-4 Number of pressure ulcers at assessment - stage 4 [CARE]
Term Description
Stage 4 - Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Observation ID in Form
G2c1
Form Coding Instructions
If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of pressure ulcers at assessment - stage 4
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52578-2 Number of pressure ulcers at assessment - unstageable [CARE]
Term Description
Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed. Include ulcers that are known or likely, but are not stageable due to non-removable dressing, device, cast or suspected deep tissue injury in evolution.
Observation ID in Form
G2d1
Fully-Specified Name
- Component
- Number of pressure ulcers at assessment - unstageable
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52579-0 Number of pressure ulcers onset during this service - stage 2 [CARE]
Term Description
Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (excludes those resulting from skin tears, tape stripping, or incontinence associated dermatitis).
Observation ID in Form
G2a2
Form Coding Instructions
If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of pressure ulcers onset during this service - stage 2
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52580-8 Number of pressure ulcers onset during this service - stage 3 [CARE]
Term Description
Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Observation ID in Form
G2b2
Form Coding Instructions
If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of pressure ulcers onset during this service - stage 3
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52581-6 Number of pressure ulcers onset during this service - stage 4 [CARE]
Term Description
Stage 4 - Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Observation ID in Form
G2c2
Form Coding Instructions
If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of pressure ulcers onset during this service - stage 4
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52582-4 Number of pressure ulcers onset during this service - unstageable [CARE]
Term Description
Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed. Include ulcers that are known or likely, but are not stageable due to non-removable dressing, device, cast or suspected deep tissue injury in evolution.
Observation ID in Form
G2d2
Fully-Specified Name
- Component
- Number of pressure ulcers onset during this service - unstageable
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52583-2 Number of unhealed stage 2 ulcers known to be present for more than 1 month [CARE]
Observation ID in Form
G2e
Form Coding Instructions
If the patient has one or more unhealed stage 2 pressure ulcers, record the number present today that were first observed more than 1 month ago, according to the best available records. If the patient has no unhealed stage 2 pressure ulcers, record "0."
Source: Centers for Medicare & Medicaid ServicesForm Coding Instructions
If the patient has one or more unhealed stage 2 pressure ulcers, record the number present today that were first observed more than 1 month ago, according to the best available records. If the patient has no unhealed stage 2 pressure ulcers, record "0"
Source: Centers for Medicare & Medicaid ServicesForm Coding Instructions
If the resident has one or more unhealed Stage 2 pressure ulcers, record the number present today that were first observed more than one month ago
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of unhealed stage 2 ulcers known to be present for more than 1 month
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Normative Answer List LL555-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| 0 ulcers | 0 | LA9916-3 | |
| 1 ulcer | 1 | LA9917-1 | |
| 2 ulcers | 2 | LA9918-9 | |
| 3 ulcers | 3 | LA9920-5 | |
| 4 ulcers | 4 | LA9921-3 | |
| 5 ulcers | 5 | LA9922-1 | |
| 6 ulcers | 6 | LA9923-9 | |
| 7 ulcers | 7 | LA9924-7 | |
| 8 or more ulcers | 8 | LA9925-4 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | 9 | LA4489-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
Example Units
| Unit | Source |
|---|---|
| {#} | Example UCUM Units |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52477-7 If any pressure ulcer is stage 3 or 4 (or if eschar is present), please record the most recent measurements for the LARGEST ulcer (or eschar):
Observation ID in Form
G3
Form Coding Instructions
If the patient has one or more unhealed (non-epithelialized) Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar, identify the pressure ulcer with the largest surface area (length x width) and record in centimeters
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Largest pressure ulcer measurements
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
Long Common Name
Largest Ulcer Measurements
Basic Attributes
- Class
- PANEL.SURVEY.MDS
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.73 (NAM)
- Change Reason
- Release 2.73: COMPONENT: update older "ulcer" terms in panels;
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
| 54580-6 | Deprecated Minimum Data Set - version 3.0 |
52728-3 Pressure Ulcer Length
Observation ID in Form
G3a
Form Coding Instructions
Longest length from head to toe
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Diameter.any.max
- Property
- Len
- Time
- Pt
- System
- Pressure injury.largest stage 3 or 4
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Diameter.any.max Pressure injury.largest stage 3 or 4 [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
- Change Reason
- Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.CARE to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
| 54580-6 | Deprecated Minimum Data Set - version 3.0 |
Example Units
| Unit | Source |
|---|---|
| cm | Example UCUM Units |
52729-1 Pressure Ulcer Width:
Observation ID in Form
G3b
Fully-Specified Name
- Component
- Diameter.transverse
- Property
- Len
- Time
- Pt
- System
- Pressure injury.largest stage 3 or 4
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Diameter transverse Pressure injury.largest stage 3 or 4 [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.63 (MIN)
- Change Reason
- Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
| 54580-6 | Deprecated Minimum Data Set - version 3.0 |
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
Example Units
| Unit | Source |
|---|---|
| cm | Example UCUM Units |
57228-9 Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the depth of the deepest area
Term Description
Depth of same unhealed ulcer or eschar
Observation ID in Form
G3c
Form Coding Instructions
Enter 99.9 if the largest ulcer is unstageable and is not eschar
Source: Regenstrief HelpFully-Specified Name
- Component
- Depth
- Property
- Len
- Time
- RptPeriod
- System
- Pressure injury.largest stage 3 or 4
- Scale
- Qn
- Method
- CMS Assessment
Long Common Name
Depth during assessment period [CMS Assessment] Pressure injury.largest stage 3 or 4
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77 (MAJ)
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.OASIS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
| 86522-0 | Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment] |
| 86872-9 | Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment] |
| 86871-1 | Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment] |
| 86873-7 | Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment] |
| 86856-2 | Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment] |
| 86876-0 | Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment] |
| 88282-9 | Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment] |
| 88283-7 | Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment] |
| 88284-5 | Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment] |
| 88285-2 | Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment] |
| 88287-8 | Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment] |
| 88292-8 | Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment] |
| 88288-6 | Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment] |
| 54580-6 | Deprecated Minimum Data Set - version 3.0 |
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
Example Units
| Unit | Source |
|---|---|
| cm | Example UCUM Units |
52584-0 Date measured
Observation ID in Form
G3d
Fully-Specified Name
- Component
- Date of ulcer measurement
- Property
- Date
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
- CARE
Long Common Name
Date of ulcer measurement [CARE]
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
52730-9 Indicate if any unhealed stage 3 or stage 4 pressure ulcer(s) has undermining and/or tunneling (sinus tract) present.
Observation ID in Form
G4
Fully-Specified Name
- Component
- Undermining or tunneling present
- Property
- Find
- Time
- Pt
- System
- Pressure injury.stage 3 or 4
- Scale
- Ord
- Method
- CARE
Long Common Name
Undermining or tunneling present Pressure injury.stage 3 or 4 [CARE]
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
- Change Reason
- "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC
Normative Answer List LL556-2
| 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 | |
| Unable to assess | 8 | LA10105-7 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52585-7 Major wound (excluding pressure ulcers). Does the patient have one or more major wound(s) that require ongoing care because of draining, infection, or delayed healing?
Form Coding Instructions
e.g., burns
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Major wound (excluding pressure ulcers)
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Ord
- Method
- CARE
Long Common Name
Major wound (excluding pressure ulcers) [CARE]
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
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 |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.
52478-5 Number of Major Wounds
Observation ID in Form
G5a-e
Form Coding Instructions
Must fill in all choices
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Number of Major Wounds
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
52586-5 Delayed healing of surgical wound # [CARE]
Observation ID in Form
G5a
Fully-Specified Name
- Component
- Delayed healing of surgical wound
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
Example Units
| Unit | Source |
|---|---|
| {#} | Example UCUM Units |
52587-3 Trauma-related wound #
Term Description
e.g., burns
Observation ID in Form
G5b
Fully-Specified Name
- Component
- Trauma-related wound
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MAJ)
- Change Reason
- Method removed because this generic term can be used across contexts
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
Example Units
| Unit | Source |
|---|---|
| {#} | Example UCUM Units |
52588-1 Diabetic foot ulcer(s) #
Observation ID in Form
G5c
Fully-Specified Name
- Component
- Diabetic foot ulcer(s)
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MAJ)
- Change Reason
- Method removed because this generic term can be used across contexts
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
Example Units
| Unit | Source |
|---|---|
| {#} | Example UCUM Units |
52589-9 Vascular ulcer (arterial or venous including diabetic ulcers not located on the foot) # [CARE]
Observation ID in Form
G5d
Fully-Specified Name
- Component
- Vascular ulcer (arterial or venous including diabetic ulcers not located on the foot)
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
Example Units
| Unit | Source |
|---|---|
| {#} | Example UCUM Units |
52590-7 Other
Term Description
(e.g., incontinence associated dermatitis, normal surgical wound healing).
Observation ID in Form
G5e
Fully-Specified Name
- Component
- Major wound.other
- Property
- Num
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
- CARE
Long Common Name
Major wound.other # [CARE]
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
Example Units
| Unit | Source |
|---|---|
| {#} | Example UCUM Units |
52591-5 Please specify:
Observation ID in Form
G5e
Fully-Specified Name
- Component
- Major wound.other
- Property
- Type
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
- CARE
Long Common Name
Major wound.other [CARE]
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |
52592-3 Turning surfaces not intact [CARE]
Observation ID in Form
G6
Form Coding Instructions
Check all that apply
Source: Centers for Medicare & Medicaid ServicesForm Coding Instructions
Check all that apply.
Source: Centers for Medicare & Medicaid ServicesForm Coding Instructions
Indicate which of the following turning surfaces have either a pressure ulcer or major wound
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Turning surfaces not intact
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nom
- Method
- CARE
Basic Attributes
- Class
- SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.26
- Last Updated
- Version 2.64 (MIN)
Normative Answer List LL557-0
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Skin for all turning surfaces is intact | a | LA10081-0 | |
| Right hip not intact | b | LA10071-1 | |
| Left hip not intact | c | LA9993-2 | |
| Back/buttocks not intact | d | LA9935-3 | |
| Other turning surface(s) not intact | e | LA10051-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 52745-7 | Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge |
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care |
| 52748-1 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission |
| 52746-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim |
| 52744-0 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission |