99179-4 Administrative Information

Observation ID in Form

A

Fully-Specified Name

Component

OASIS E - Administrative information - DC

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.72

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

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

Related Codes

46500-5 Discipline of Person Completing Assessment

Term Description

Identifies the discipline of the clinician completing the comprehensive assessment at the specified time points or the clinician reporting the transfer to an inpatient facility, death at home, or discharge (no further visits after start of care).
Source: Regenstrief LOINC

Observation ID in Form

M0080

Fully-Specified Name

Component

Discipline of person completing assessment

Property

Type

Time

RptPeriod

System

Provider

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

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 OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL245-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Nominal
• Persons
• Report period
• Survey
• Typ

Related Codes

46501-3 Date Assessment Completed

Term Description

The actual date the assessment is completed, except if agency policy allows assessments to be performed over more than one visit date, in which case the last date (when the assessment is finished) is the appropriate date to record.
Source: Regenstrief LOINC

Observation ID in Form

M0090

Fully-Specified Name

Component

Date assessment information completed

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

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 OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

57200-8 This Assessment is Currently Being Completed for the Following Reason

Observation ID in Form

M0100

Fully-Specified Name

Component

Reason for assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL773-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

46582-3 Discharge/Transfer/Death Date

Term Description

Identifies the actual date of discharge, transfer, or death.
Source: Regenstrief LOINC

Observation ID in Form

M0906

Form Coding Instructions

Enter the date of the discharge, transfer, or death (at home) of the patient.

Fully-Specified Name

Component

Discharge, transfer, death date

Property

Date

Time

Pt

System

^Patient

Scale

Qn

Method

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.71

Change Reason

Release 2.71: METHOD_TYP: Removed Method because this concept is not specific to CMS; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

• Disch
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Survey

Example Units

Related Codes

101351-5 Transportation. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Observation ID in Form

A1250

Fully-Specified Name

Component

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.74

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

Observation

Normative Answer List LL6295-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Job
• Nominal
• Occupation
• Report period
• 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.

57276-8 Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?

Observation ID in Form

M2301

Skip Logic

If 0, Skip to M2410, Inpatient Facility. If NA, Skip to M2410, Inpatient Facility.

Fully-Specified Name

Component

Emergent care utilized

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clincal LOINC committee;Added "utilized" to the Component to further clarify the term and to differeniate from the panel term 85906-6; Changed Scale to Ord because of the ordinal answer choices; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL824-4

Member of these Panels

Related Names

• 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.

57277-6 Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)?

Observation ID in Form

M2310

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Reason for emergent care

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee;Moved Survey Question Text to Override Display Name to account for variation across CMS forms

Order vs. Observation

Observation

Normative Answer List LL4874-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

46578-1 To which Inpatient Facility has the patient been admitted?

Term Description

Identifies the type of inpatient facility to which the patient was admitted.
Source: Regenstrief LOINC

Observation ID in Form

M2410

Fully-Specified Name

Component

Admitted to

Property

Type

Time

RptPeriod

System

Inpatient facility

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

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 OASIS 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; Changed Component to "Admitted to" and System to "Inpatient facility" to match LOINC convention for terms about facilities

Order vs. Observation

Observation

Normative Answer List LL4546-9

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• IP
• Nominal
• Report period
• Survey
• Transferred
• Typ

Related Codes

55128-3 Discharge disposition: Where is the patient after discharge from your agency? (Choose only one answer.)

Observation ID in Form

M2420

Skip Logic

If 1, 4 or UK, Skip to A2123, Provision of Current Reconciled Medication List to Patient at Discharge. If 2 or 3 continue to A2121, Provision of Current Reconciled Medication List to Subsequent Provider at Discharge.

Fully-Specified Name

Component

Discharge disposition

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.66

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. Changed COMPONENT from "Discharge status" to "Discharge disposition" - For consistency across LOINC for concepts used to report the disposition (i.e. location or status, etc.) of the patient at discharge, "Discharge disposition" will be used. Updated the PROPERTY from "Find" to "Type" based on the LOINC model. Method removed because this generic term can be used across contexts.

Order vs. Observation

Observation

Normative Answer List LL826-9

Member of these Panels

Language Variants Get Info

Related Names

• Disch
• Discharge location
• Discharge status
• Nominal
• Point in time
• Random
• Survey
• Typ

Related Codes

93182-4 Provision of Current Reconciled Medication List to Subsequent Provider at Discharge. At the time of discharge to another provider, did your facility provide the patient's current reconciled medication list to the subsequent provider?

Observation ID in Form

A2121

Skip Logic

If 0, Skip to A2123. Provision of Current Reconciled Medication List to Patient at Discharge

Fully-Specified Name

Component

Provision of current reconciled medication list to subsequent provider at discharge

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

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

Observation

Normative Answer List LL5377-8

Member of these Panels

Related Names

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

Related Codes

93184-0 Route of Current Reconciled Medication List Transmission to Subsequent Provider. Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.

Observation ID in Form

A2122

Skip Logic

If 1, Continue to A2122, Route of Current Reconciled Medication List Transmission to Subsequent Provider.

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Route of current reconciled medication list transmission to subsequent provider

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

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

Observation

Normative Answer List LL5378-6

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Reconciled med list
• Report period
• Survey

Related Codes

93181-6 Provision of Current Reconciled Medication List to Patient at Discharge. At the time of discharge, did your facility provide the patient's current reconciled medication list to the patient, family and/or caregiver?

Observation ID in Form

A2123

Skip Logic

If 0, skip to B1300, Health Literacy. If 1, continue to A2124, Route of Current Reconciled Medication List Transmission to Patient.

Fully-Specified Name

Component

Provision of current reconciled medication list to patient at discharge

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

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

Observation

Normative Answer List LL5379-4

Member of these Panels

Related Names

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

Related Codes

93183-2 Route of Current Reconciled Medication List Transmission to Patient. Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver.

Observation ID in Form

A2124

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Route of current reconciled medication list transmission to patient

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

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

Observation

Normative Answer List LL5380-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Reconciled med list
• Report period
• Survey

Related Codes

93166-7 Hearing, Speech, and Vision

Observation ID in Form

B

Fully-Specified Name

Component

IRF-PAI v4.0, OASIS E - Hearing, speech, and vision - ROC, DC

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.67

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 2.72: COMPONENT: Updated to include current version of OASIS that uses this panel;

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

Related Codes

103709-2 Health Literacy. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?

Observation ID in Form

B1300

Fully-Specified Name

Component

How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Survey Question

Text

How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?

Source

Single Item Literacy Screener

Normative Answer List LL4911-5

Member of these Panels

Related Names

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

Related Codes

Copyright

Organization

Dr. Nancy Morris

Copyright

© 2006 Morris et al.

Terms of Use

Used with permission

99140-6 Cognitive Patterns

Observation ID in Form

C

Fully-Specified Name

Component

OASIS E - Cognitive Patterns - SOC, ROC, DC

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.72

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
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

46589-8 Cognitive Functioning

Term Description

Identifies the patient's current level of cognitive functioning, including alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
Source: Regenstrief LOINC

Observation ID in Form

M1700

Fully-Specified Name

Component

Cognitive functioning

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

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 OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL281-7

Member of these Panels

Related Names

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

Related Codes

58104-1 When Confused

Observation ID in Form

M1710

Form Coding Instructions

Reported or observed within the last 14 days.

Fully-Specified Name

Component

When confused within the last 14D

Property

Find

Time

14D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.61

Change Reason

Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee;Removed "reported or observed" from the COMPONENT because an oberservation of this nature must either be reported or observed, and therefore stating so is redundant;Changed "days" to "D" to match LOINC conventions for abbreviating time

Order vs. Observation

Observation

Normative Answer List LL282-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• When confused reported or observed within the last 14D

Related Codes

86495-9 When Anxious

Observation ID in Form

M1720

Form Coding Instructions

Reported or observed within the last 14 days.

Fully-Specified Name

Component

When anxious within the last 14D

Property

Find

Time

14D

System

^Patient

Scale

Ord

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 LL283-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

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

Observation ID in Form

C0100

Skip Logic

If 0, Skip to C1310 Signs and Symptoms of Delirium (from CAM©)

Form Coding Instructions

Attempt to conduct interview with all patients.

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.

103694-6 Brief Interview for Mental Status

Fully-Specified Name

Component

Brief interview for mental status

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Both

Panel Type

Panel

Member of these Panels

Related Names

• BIMS
• Centers for Medicare and Medicaid Assessment
• Report period
• Survey

103696-1 Repetition of Three Words

Observation ID in Form

C0200

Form Coding Instructions

After the patient'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

Ask patient: "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."

Fully-Specified Name

Component

Repetition of three words

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL687-5

Member of these Panels

Related Names

• 3
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• Number
• 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.

103702-7 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

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Report period
• Survey
• Temporal orientation (orientation to year, month, and day) - MDSv3

Related Codes

103697-9 Able to report correct year

Observation ID in Form

C0300A

Form Coding Instructions

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

Fully-Specified Name

Component

Temporal orientation - current year

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL643-8

Member of these Panels

Related Names

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

Related Codes

103698-7 Able to report correct month

Observation ID in Form

C0300B

Form Coding Instructions

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

Fully-Specified Name

Component

Temporal orientation - current month

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL644-6

Member of these Panels

Related Names

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

Related Codes

103703-5 Able to report correct day of the week

Observation ID in Form

C0300C

Form Coding Instructions

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

Fully-Specified Name

Component

Temporal orientation - current day of the week

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL645-3

Member of these Panels

Related Names

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

Related Codes

103695-3 Recall

Observation ID in Form

C0400

Form Coding Instructions

Ask patient: "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

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Report period
• Survey

Related Codes

103699-5 Able to recall "sock"

Observation ID in Form

C0400A

Fully-Specified Name

Component

Recall - sock

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL646-1

Member of these Panels

Related Names

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

Related Codes

103700-1 Able to recall "blue"

Observation ID in Form

C0400B

Fully-Specified Name

Component

Recall - blue

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL647-9

Member of these Panels

Related Names

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

Related Codes

103701-9 Able to recall "bed"

Observation ID in Form

C0400C

Fully-Specified Name

Component

Recall - bed

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL648-7

Member of these Panels

Related Names

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

Related Codes

103704-3 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

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Member of these Panels

Related Names

• BIMS
• BIMS summary score
• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Scale
• Survey

Example Units

Related Codes

95816-5 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

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 2.69

Last Updated

Version 2.72

Order vs. Observation

Order

Panel Type

Panel

Member of these Panels

Related Names

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

Related Codes

Additional Copyright

Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission.

95813-2 Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline?

Observation ID in Form

C1310A

Fully-Specified Name

Component

Is there evidence of an acute change in mental status from the patient's baseline

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.69

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
• Ql
• Qual
• Qualitative
• Replace
• Report period
• S prime
• 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.

95812-4 Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?

Observation ID in Form

C1310B

Fully-Specified Name

Component

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

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.69

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
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• 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/

95814-0 Disorganized thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

Observation ID in Form

C1310C

Fully-Specified Name

Component

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

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.69

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

• Arterial Stenosis
• Dynamic
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• S prime
• Screen
• Survey