54605-1 Should Brief Interview for Mental Status (C0200-C0500) be Conducted?

Observation ID in Form

C0100

Skip Logic

If 0, Skip to and complete C0700-C1000, Staff Assessment for Mental Status. If 1, Continue to C0200, Repetition of Three Words.

Form Coding Instructions

Attempt to conduct interview with all residents

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

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

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. Number of words repeated after first attempt

Observation ID in Form

C0200

Form Coding Instructions

Ask resident: "I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words."

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

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

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)

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

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 Able to report correct year

Observation ID in Form

C0300A

Form Coding Instructions

Ask resident: "Please tell me what year it is right now."

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

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 Able to report correct month

Observation ID in Form

C0300B

Form Coding Instructions

Ask resident: "What month are we in right now?"

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

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 Able to report correct day of the week

Observation ID in Form

C0300C

Form Coding Instructions

Ask resident: "What day of the week is today?"

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

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

Observation ID in Form

C0400

Form Coding Instructions

Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (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

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

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 BIMS 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 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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

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 0, Skip to C1310, Signs and Symptoms of Delirium. If 1, 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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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 LL4658-2

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

86595-6 Staff Assessment for Mental Status

Skip Logic

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

Fully-Specified Name

Component

MDS v3.0 - RAI v1.16.1 - Staff assessment for mental status

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Release 2.68: COMPONENT: Assessment version number was updated to reflect the most recent version.; Previous Releases: This panel is in version 1.14.1, 1.15.1, and 1.16.1. So "v1.16.1" was added to the Component; Current convention (as approved by the joint CMS LTPAC & LOINC project team) will list only the most current assessment in the Component for CMS Assessment panels.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

54616-8 Short-term Memory OK. Seems or appears to recall after 5 minutes

Observation ID in Form

C0700

Fully-Specified Name

Component

Short-term memory OK

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 2.70

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. Seems or appears to recall long past

Observation ID in Form

C0800

Fully-Specified Name

Component

Long-term memory OK

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 2.70

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

86583-2 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 in the last 7D

Property

Find

Time

7D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.63

Order vs. Observation

Observation

Normative Answer List LL4556-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Memory/recall ability
• Nominal
• Past
• Survey

Related Codes

54624-2 Cognitive Skills for Daily Decision Making. Made decisions regarding tasks of daily life

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70

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

86584-0 Delirium

Fully-Specified Name

Component

Delirium

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

86585-7 Signs and Symptoms of Delirium (from CAM)

Observation ID in Form

C1310

Form Coding Instructions

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

Fully-Specified Name

Component

MDS v3.0 - RAI v1.17.2, OASIS E - Signs and symptoms of delirium (from CAM)

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.78

Change Reason

Release 2.78: ORDER_OBS: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”; PanelType: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”; Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Release 2.72: COMPONENT: Updated to include current version of OASIS that uses this panel; Release 2.68: COMPONENT: Assessment version number was updated to reflect the most recent version.; Previous Releases: This panel is in version 1.14.1, 1.15.1, and 1.16.1. So "v1.16.1" was added to the Component; Current convention (as approved by the joint CMS LTPAC & LOINC project team) will list only the most current assessment in the Component for CMS Assessment panels.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey
• Sx

Related Codes

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

C1310A

Fully-Specified Name

Component

Acute onset mental status change

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67

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

Survey Question

Text

[Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline?

Source

CAM.1

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

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.

54628-3 Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?

Reference Information

Observation ID in Form

C1310B

Fully-Specified Name

Component

Inattention in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Nom

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67

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

Survey Question

Text

[Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

Source

CAM.2A

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

C1310C

Fully-Specified Name

Component

Disorganized thinking in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67

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

Survey Question

Text

[Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

Source

CAM.3

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, as indicated by any of the following criteria?

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)"
Source: Regenstrief LOINC

Reference Information

Observation ID in Form

C1310D

Fully-Specified Name

Component

Altered level of consciousness in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.72

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

Survey Question

Text

Altered level of consciousness. Did the resident have altered level of consciousness? (e.g., vigilant - startled easily to any sound or touch; lethargic- repeatedly dozed off when being asked questions, but responded to voice or touch; stuporous-very difficult to arouse and keep aroused for the interview; comatose - could not be aroused)

Source

CMS

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/