54605-1 Brief Interview for Mental Status (BIMS) should be conducted during assessment period [CMS Assessment]

Observation ID in Form

C0100

Skip Logic

If No, (resident is rarely/never understood), Skip to and complete C0700-C1000, Staff Assessment for Mental Status. If Yes, Continue to C0200, Repetition of Three Words.

Fully-Specified Name

Component

Brief interview for mental status should be conducted

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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.MDS to SURVEY.CMS because term is used across CMS assessments. Removed Survey Question Text and Source since that information is included in other parts of the term;

Order vs. Observation

Observation

Normative Answer List LL691-7

Member of these Panels

Related Names

• BIMS
• BIMS should be conducted
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

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.

52491-8 Brief interview for mental status [BIMS]

Fully-Specified Name

Component

Brief interview for mental status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

BIMS

Basic Attributes

Class

PANEL.SURVEY.BIMS

Type

Surveys

First Released

Version 2.24

Last Updated

Version 2.67 (PANEL)

Change Reason

Removed (BIMS) since included in LNC override; Added Method of BIMS to include across CMS panels

Order vs. Observation

Both

Panel Type

Panel

Member of these Panels

Related Names

• Brief Interview for Mental Status (BIMS) Pnl
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

52731-7 Repetition of three words # [BIMS]

Observation ID in Form

C0200

Form Coding Instructions

After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture"). You may repeat the words up to two more times

Form Coding Instructions

After the patient's first attempt say: "I will repeat each of the three words with a cue and ask you about them later: sock, something to wear; blue, a color; bed, a piece of furniture." You may repeat the words up to two more times

Fully-Specified Name

Component

Repetition of three words

Property

Num

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Removed "Observed." from method to make consistent with other survey methods; Changed property to Num to match answer list

Order vs. Observation

Observation

Normative Answer List LL687-5

Member of these Panels

Related Names

• 3
• Brief Interview for Mental Status
• Cnt
• Count
• Number
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

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.

54510-3 Temporal orientation (orientation to year, month, and day) [BIMS]

Observation ID in Form

C0300

Fully-Specified Name

Component

Temporal orientation (orientation to year, month, and day)

Property

-

Time

Pt

System

^Patient

Scale

-

Method

BIMS

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67 (PANEL)

Change Reason

Removed MDSv3 from component and added method of BIMS so that term can be used across CMS panels.; Changed Class from SURVEY.MDS to PANEL.SURVEY.CMS

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Point in time
• Random
• Survey
• Temporal orientation (orientation to year, month, and day) - MDSv3

52732-5 Temporal orientation - current year [BIMS]

Observation ID in Form

C0300A

Fully-Specified Name

Component

Temporal orientation - current year

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Order vs. Observation

Observation

Normative Answer List LL643-8

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52733-3 Temporal orientation - current month [BIMS]

Observation ID in Form

C0300B

Fully-Specified Name

Component

Temporal orientation - current month

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Removed "Observed." from method to follow convention of other survey terms

Order vs. Observation

Observation

Normative Answer List LL644-6

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

54609-3 Temporal orientation - current day of the week [BIMS]

Observation ID in Form

C0300C

Fully-Specified Name

Component

Temporal orientation - current day of the week

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Removed "Observed." and ".MDS" from method to follow convention of other survey terms and to include term across CMS assessments

Order vs. Observation

Observation

Normative Answer List LL645-3

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52493-4 Recall [BIMS]

Observation ID in Form

C0400

Form Coding Instructions

Ask patient: "Let's go back to the first question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (i.e. something to wear; a color; a piece of furniture) for that word

Fully-Specified Name

Component

Recall

Property

-

Time

Pt

System

^Patient

Scale

-

Method

BIMS

Basic Attributes

Class

PANEL.SURVEY.BIMS

Type

Surveys

First Released

Version 2.24

Last Updated

Version 2.67 (PANEL)

Change Reason

Added method of BIMS

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Brief Interview for Mental Status (BIMS) Pnl
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

52735-8 Able to recall "sock"

Observation ID in Form

C0400A

Fully-Specified Name

Component

Recall - sock

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Long Common Name

Recall - sock [BIMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL646-1

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52736-6 Able to recall "blue"

Observation ID in Form

C0400B

Fully-Specified Name

Component

Recall - blue

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Long Common Name

Recall - blue [BIMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL647-9

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52737-4 Able to recall "bed"

Observation ID in Form

C0400C

Fully-Specified Name

Component

Recall - bed

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Long Common Name

Recall - bed [BIMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL648-7

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

54614-3 Summary Score

Observation ID in Form

C0500

Form Coding Instructions

Add scores for questions C0200-C0400 and fill in total score (00-15). Enter 99 if unable to complete one or more questions of the interview

Form Coding Instructions

Add scores for questions C0200 - C0400 and fil in total score (00 - 15). Enter 99 if unable to complete one or more questions of the interview

Form Coding Instructions

Add scores for each question and fill in total score (00-15). Enter 99 if the resident was unable to complete interview

Fully-Specified Name

Component

Brief interview for mental status - summary score

Property

Score

Time

Pt

System

^Patient

Scale

Qn

Method

BIMS

Long Common Name

Brief Interview for Mental Status - summary score [BIMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Changed method to BIMS so term can be used across CMS assessments; Updated CLASS to SURVEY.CMS; Removed (BIMS) from Component because it is repeated in the Method

Order vs. Observation

Observation

Member of these Panels

Related Names

• BIMS summary score
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Scale
• Survey

Example Units

54615-0 Should the Staff Assessment for Mental Status C0700-C1000 be conducted?

Observation ID in Form

C0600

Skip Logic

If No, (resident was able to complete interview), Skip to C1300, Signs and Symptoms of Delirium. If Yes, (resident was unable to complete interview), Continue to C0700, Short-term Memory OK.

Fully-Specified Name

Component

Should staff assessment for mental status be conducted

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Should staff assessment for mental status be conducted during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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 from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL688-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Staff assessment for mental status should be conducted
• Survey

Related Codes

54895-8 Staff assessment for mental status [MDSv3]

Skip Logic

Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.

Fully-Specified Name

Component

Staff assessment for mental status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

MDSv3

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• MDS version 3
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS

54616-8 Short-term Memory OK

Observation ID in Form

C0700

Fully-Specified Name

Component

Short-term memory OK

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Short-term memory OK during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70 (NAM)

Change Reason

Release 2.70: COMPONENT: Removed "in last 7D"; TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG;Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments

Order vs. Observation

Observation

Normative Answer List LL11-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

54617-6 Long-term memory OK

Observation ID in Form

C0800

Form Context

Seems or appears to recall long past

Fully-Specified Name

Component

Long-term memory OK

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Long-term memory OK during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70 (NAM)

Change Reason

Release 2.70: COMPONENT: Removed "in last 7D"; TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG;Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments

Order vs. Observation

Observation

Normative Answer List LL11-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

54618-4 Memory/Recall Ability

Observation ID in Form

C0900

Form Coding Instructions

Check all that the resident was normally able to recall

Fully-Specified Name

Component

Memory &or recall ability

Property

-

Time

Pt

System

^Patient

Scale

-

Method

MDSv3

Long Common Name

Memory/recall ability [MDSv3]

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• MDS version 3
• Memory/recall ability
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS

54619-2 Current season

Observation ID in Form

C0900A

Fully-Specified Name

Component

Can recall current season in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Can recall current season in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

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.

54620-0 Location of own room

Observation ID in Form

C0900B

Fully-Specified Name

Component

Can recall location of own room in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Can recall location of own room in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

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.

54621-8 Staff names and faces

Observation ID in Form

C0900C

Fully-Specified Name

Component

Can recall staff names and faces in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Can recall staff names and faces in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

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.

54622-6 That he or she is in a nursing home

Observation ID in Form

C0900D

Fully-Specified Name

Component

Can recall that he or she is in a nursing home in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Can recall that he or she is in a nursing home in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

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.

54623-4 None of the above were recalled

Observation ID in Form

C0900Z

Fully-Specified Name

Component

None of the above were recalled in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

None of the above were recalled in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

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.

54624-2 Cognitive skills for daily decision making

Observation ID in Form

C1000

Fully-Specified Name

Component

Cognitive skills for daily decision making

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Cognitive skills for daily decision making during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70 (NAM)

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 7D"; Previous Releases: Updated METHOD from MDSv3 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

Order vs. Observation

Observation

Normative Answer List LL650-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Decision-making
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

54626-7 Delirium [MDSv3]

Fully-Specified Name

Component

Delirium

Property

-

Time

Pt

System

^Patient

Scale

-

Method

MDSv3

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• MDS version 3
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS

54627-5 Signs and symptoms of delirium (from CAM) [CAM.MDSv3]

Reference Information

Observation ID in Form

C1300

Form Coding Instructions

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record

Webcontent

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990 Dec 15;113(12):941-8.

Fully-Specified Name

Component

Signs and symptoms of delirium (from CAM)

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Observed.CAM.MDSv3

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• MDS version 3
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS
• Sx

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

54628-3 Inattention. Did the resident have difficulty focusing attention (easily distracted, out of touch or difficulty following what was said)?

Reference Information

Observation ID in Form

C1300A

Fully-Specified Name

Component

Inattention in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Nom

Method

CAM.CMS

Long Common Name

Inattention in last 7 days [CAM.CMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67 (MAJ)

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; SURVEY_QUEST_SRC: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; Previous Releases: 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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.; Scale changed from Ord to Nom because answers cannot be ordered

Order vs. Observation

Observation

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Nominal
• Past
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

54629-1 Disorganized thinking. Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

Reference Information

Observation ID in Form

C1300B

Fully-Specified Name

Component

Disorganized thinking in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

CAM.CMS

Long Common Name

Disorganized thinking in last 7 days [CAM.CMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67 (MAJ)

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; SURVEY_QUEST_SRC: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; Previous Releases: 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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

54630-9 Altered level of consciousness. Did the resident have altered level of consciousness?

Term Description

This term is the CMS Assessment adaption of question 4 on the Confusion Assessment Method (CAM): "[Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)"

Reference Information

Observation ID in Form

C1300C

Fully-Specified Name

Component

Altered level of consciousness in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

CAM.CMS

Long Common Name

Altered level of consciousness in last 7 days [CAM.CMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.72 (MIN)

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); Previous Releases: 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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Levels
• Levl
• LV
• LVL
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

54631-7 Psychomotor retardation. Did the resident have an unusually decreased level of ctivity such as sluggishness, staring into space, staying in one position, moving very slowly?

Observation ID in Form

C1300D

Fully-Specified Name

Component

Psychomotor retardation in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

Observed.CAM.MDSv3

Long Common Name

Psychomotor retardation in last 7 days [CAM.MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

54632-5 Acute Onset Mental Status Change - Is there evidence of an acute change in mental status from the resident's baseline?

Reference Information

Observation ID in Form

C1600

Fully-Specified Name

Component

Acute onset mental status change

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CAM.CMS

Long Common Name

Acute onset mental status change [CAM.CMS]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67 (MAJ)

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; Previous Releases: 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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Exchange
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Replace
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

Third Party Copyright

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