Version 2.78

69349-9 Presence of pressure ulcers

Observation ID in Form

G1-2

Fully-Specified Name

Component
Presence of pressure ulcers - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

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

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Is this patient at risk of developing pressure ulcers?
Source
CARE I.g01

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

52574-1 Does this patient have one or more unhealed pressure ulcer(s) at stage 2 or higher?

Observation ID in Form

G2

Skip Logic

If No, skip to G5. Major Wounds.

Fully-Specified Name

Component
One or more unhealed pressure ulcer(s) at stage 2 or higher
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Does this patient have one or more unhealed pressure ulcer(s) at stage 2 or higher?
Source
CARE I.g02

Normative Answer List LL361-7

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) LA32-8

Member of these Panels

LOINC Long Common Name
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
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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:
Source: Regenstrief LOINC

Form Coding Instructions

CODING: Please specify the number of ulcers at each stage:

Source: Centers for Medicare & Medicaid Services

Fully-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

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
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).
Source: Regenstrief LOINC

Observation ID in Form

G2a1

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 Services

Fully-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

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

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.
Source: Regenstrief LOINC

Observation ID in Form

G2b1

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 Services

Fully-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

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

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.
Source: Regenstrief LOINC

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 Services

Fully-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

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

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.
Source: Regenstrief LOINC

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

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

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).
Source: Regenstrief LOINC

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 Services

Fully-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

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

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.
Source: Regenstrief LOINC

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 Services

Fully-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

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

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.
Source: Regenstrief LOINC

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 Services

Fully-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

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

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.
Source: Regenstrief LOINC

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

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

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 Services

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 Services

Form 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 Services

Fully-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

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

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 Services

Fully-Specified Name

Component
Largest pressure ulcer measurements
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.MDS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.73
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 Longest length in any direction

Observation ID in Form

G3a

Fully-Specified Name

Component
Diameter.any.max
Property
Len
Time
Pt
System
Pressure injury.largest stage 3 or 4
Scale
Qn
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63
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

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63
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

52584-0 Date of measurement

Fully-Specified Name

Component
Date of ulcer measurement
Property
Date
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

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

G3c

Fully-Specified Name

Component
Undermining or tunneling present
Property
Find
Time
Pt
System
Pressure injury.stage 3 or 4
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
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

Survey Question

Text
Indicate if any unhealed stage 3 or stage 4 pressure ulcer(s) has undermining and/or tunneling (sinus tract) present.
Source
CARE I.g04

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

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?

Observation ID in Form

G5

Form Coding Instructions

e.g., burns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Major wound (excluding pressure ulcers)
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
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?
Source
CARE I.g05

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

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 Services

Fully-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
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

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
Source: Regenstrief LOINC

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
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
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

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).
Source: Regenstrief LOINC

Observation ID in Form

G5e

Fully-Specified Name

Component
Major wound.other
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

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.1

Fully-Specified Name

Component
Major wound.other
Property
Type
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

Survey Question

Text
Please specify:
Source
CARE G5e.1

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 Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Indicate which of the following turning surfaces have either a pressure ulcer or major wound

Source: Centers for Medicare & Medicaid Services

Fully-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

Survey Question

Source
CARE I.G6

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