57194-3  Outcome and assessment information set (OASIS) form - version C - Discharge from agencyOutcome and assessment information set (OASIS) form - version C - Discharge from agencyOutcome and assessment information set (OASIS) form - version C - Discharge from agency: -: Pt: ^Patient: -:  

PANEL HIERARCHY

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  57194-3   Outcome and assessment information set (OASIS) form - version C - Discharge from agencyOutcome and assessment information set (OASIS) form - version C - Discharge from agencyOutcome and assessment information set (OASIS) form - version C - Discharge from agency: -: Pt: ^Patient: -:    
       57040-8   Clinical Record Items [CMS Assessment]Clinical Record Items [CMS Assessment]Clinical record items: -: Pt: ^Patient: -: CMS Assessment    
            46500-5   Discipline of Person Completing Assessment    
            46501-3   Date Assessment Completed   {mm/dd/yyyy} 
            57200-8   This Assessment is Currently Being Completed for the Following Reason:    
            57201-6   Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment]Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment]Date of Physician-ordered Start of Care (Resumption of Care): Date: Pt: ^Patient: Qn: CMS Assessment   {mm/dd/yyyy} 
            57202-4   Date of ReferralDate of ReferralDate of Referral: Date: Pt: ^Patient: Qn:   {mm/dd/yyyy} 
            57203-2   Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?    
       69328-3   Patient history and diagnosis    
            57208-1   Influenza vaccination received in Reporting Period [CMS Assessment]Influenza vaccination received in Reporting Period [CMS Assessment]Influenza virus vaccination received: Find: RptPeriod: ^Patient: Ord: CMS Assessment    
            57209-9   Reason influenza virus vaccine not received [OASIS-C]Reason influenza virus vaccine not received [OASIS-C]Reason influenza virus vaccine not received: Find: Pt: ^Patient: Nom: OASIS-C    
            57210-7   Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?    
            57211-5   Reason PPV not received:    
       57042-4   Sensory status [CMS Assessment]Sensory status [CMS Assessment]Sensory status: -: Pt: ^Patient: -: CMS Assessment    
            57215-6   Vision [CMS Assessment]Vision [CMS Assessment]Vision: Find: Pt: ^Patient: Ord: CMS Assessment    
            57216-4   Ability to hear [CMS Assessment]Ability to hear [CMS Assessment]Ability to hear: Find: Pt: ^Patient: Ord: CMS Assessment    
            57217-2   Understanding of verbal content in patient's own language (with hearing aid or device if used)    
            57218-0   Speech and oral (verbal) expression of language (in patient's own language)    
            57219-8   Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient’s ability to communicate the severity of pain)?    
            57220-6   Frequency of pain interfering with patient's activity or movement:    
       57044-0   Integumentary statusIntegumentary statusIntegumentary status: -: Pt: ^Patient: -:    
            57307-1   Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"    
            57222-2   Oldest non-epithelialized stage II pressure ulcer that is present at discharge    
            58052-2   Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment]Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment]Date pressure injury first identified: Date: Pt: Pressure injury.oldest non-epithelialized stage 2: Qn: CMS Assessment   {mm/dd/yyyy} 
            58102-5   Current number of unhealed (non-epithelialized) pressure ulcers at each stage    
                 57186-9   Number currently present    
                      55124-2   Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.   {#} 
                      55125-9   Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.   {#} 
                      55126-7   Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.   {#} 
                      54893-3   Unstageable: Known or likely but unstageable due to non-removable dressing or device   {#} 
                      54946-9   Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.   {#} 
                      54950-1   Unstageable: Suspected deep tissue injury in evolution.   {#} 
                 57187-7   Number of those listed in Column 1 that were present on admission (most recent SOC/ROC)    
                      54886-7   Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.   {#} 
                      54887-5   Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.   {#} 
                      54890-9   Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.   {#} 
                      54894-1   Unstageable: Known or likely but unstageable due to non-removable dressing or device   {#} 
                      54947-7   Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.   {#} 
                      54951-9   Unstageable: Suspected deep tissue injury in evolution.   {#} 
            57188-5   Stage III and IV pressure ulcer with the largest surface dimension (length x width)    
                 57226-3   Pressure Ulcer Length:   cm 
                 52729-1   Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length   cm 
                 57228-9   Pressure Ulcer Depth:   cm 
            57229-7   Status of most problematic (observable) pressure ulcer:    
            46536-9   Current Number of Stage I Pressure Ulcers:   {#} 
            57231-3   Status of most problematic unhealed (observable) pressure ulcer:    
            57232-1   Does the patient have a Stasis Ulcer?    
            57233-9   Current Number of (Observable) Stasis Ulcer(s):   {#} 
            57234-7   Status of most problematic (observable) stasis ulcer:    
            57235-4   Does this patient have a Surgical Wound?    
            57236-2   Status of most problematic (observable) surgical wound:    
            46534-4   Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those described above, that is receiving intervention by the home health agency?    
       52510-5   Respiratory statusRespiratory statusRespiratory status: -: Pt: ^Patient: -:    
            57237-0   When is the patient dyspneic or noticeably Short of Breath?    
            57238-8   Respiratory treatments utilized at home: 1..3   
       57045-7   Cardiac statusCardiac statusCardiac status: -: Pt: ^Patient: -:    
            57239-6   Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?    
            57240-4   Heart failure follow-up [CMS Assessment]Heart failure follow-up [CMS Assessment]Heart failure follow-up: Find: Pt: ^Patient: Nom: CMS Assessment 1..5   
       57046-5   Elimination statusElimination statusElimination status: -: Pt: ^Patient: -:    
            46553-4   Urinary incontinence or urinary catheter present [CMS Assessment]Urinary incontinence or urinary catheter present [CMS Assessment]Urinary incontinence or urinary catheter present: Find: Pt: ^Patient: Ord: CMS Assessment    
            46587-2   Bowel incontinence frequency [CMS Assessment]Bowel incontinence frequency [CMS Assessment]Bowel incontinence frequency: Find: Pt: ^Patient: Ord: CMS Assessment    
            46588-0   Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen?    
       69332-5   Neuro & emotional & behavioral status    
            46589-8   Cognitive functioning [CMS Assessment]Cognitive functioning [CMS Assessment]Cognitive functioning: Find: Pt: ^Patient: Ord: CMS Assessment    
            58104-1   When confused (reported or observed within the last 14 days):    
            86495-9   When Anxious (Reported or Observed Within the Last 14 Days)    
            46473-5   Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed):    
            46592-2   Frequency of disruptive behavior symptoms (reported or observed)    
       69337-4   ADL/IADLs    
            46595-5   Grooming:    
            46597-1   Ability to dress upper body:    
            46599-7   Ability to dress lower body:    
            57243-8   Bathing:    
            57244-6   Toileting transferring:    
            57245-3   Toileting hygiene:    
            57246-1   Transferring:    
            57247-9   Ambulation/Locomotion:    
            57248-7   Feeding or eating:    
            57249-5   Ability to plan or prepare light meals    
            46569-0   Ability to use telephone:    
       52471-0   MedicationsMedicationsMedications: -: Pt: ^Patient: -:    
            57256-0   Medication intervention since admission/​reentry [CMS Assessment]Medication intervention since admission/​reentry [CMS Assessment]Medication intervention since admission &or reentry: Find: Pt: ^Patient: Ord: CMS Assessment    
            57195-0   Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?    
            57285-9   Management of oral medications:    
            57284-2   Management of injectable medications:    
       57049-9   Care management [CMS Assessment]Care management [CMS Assessment]Care management: -: Pt: ^Patient: -: CMS Assessment    
            57306-3   Types and sources of assistance [CMS Assessment]Types and sources of assistance [CMS Assessment]Types and sources of assistance: -: Pt: ^Patient: -: CMS Assessment    
                 57260-2   Non-agency caregiver ability and willingness to assist with ADL [CMS Assessment]Non-agency caregiver ability and willingness to assist with ADL [CMS Assessment]Non-agency caregiver ability and willingness to assist with ADL: Find: Pt: ^Patient: Ord: CMS Assessment    
                 57261-0   Non-agency caregiver ability and willingness to assist with IADL [CMS Assessment]Non-agency caregiver ability and willingness to assist with IADL [CMS Assessment]Non-agency caregiver ability and willingness to assist with IADL: Find: Pt: ^Patient: Ord: CMS Assessment    
                 57262-8   Non-agency caregiver ability and willingness to assist with medication administration [CMS Assessment]Non-agency caregiver ability and willingness to assist with medication administration [CMS Assessment]Non-agency caregiver ability and willingness to assist with medication administration: Find: Pt: ^Patient: Ord: CMS Assessment    
                 57263-6   Medical procedures/treatments    
                 57264-4   Non-agency caregiver ability and willingness to assist with management of equipment [CMS Assessment]Non-agency caregiver ability and willingness to assist with management of equipment [CMS Assessment]Non-agency caregiver ability and willingness to assist with management of equipment: Find: Pt: ^Patient: Ord: CMS Assessment    
                 57265-1   Non-agency caregiver ability and willingness to assist with supervision and safety [CMS Assessment]Non-agency caregiver ability and willingness to assist with supervision and safety [CMS Assessment]Non-agency caregiver ability and willingness to assist with supervision and safety: Find: Pt: ^Patient: Ord: CMS Assessment    
                 57266-9   Advocacy or facilitation    
            57267-7   How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?    
       57052-3   Emergent care [CMS Assessment]Emergent care [CMS Assessment]Emergent care: -: Pt: ^Patient: -: CMS Assessment    
            57276-8   Emergent care utilized [CMS Assessment]Emergent care utilized [CMS Assessment]Emergent care utilized: Find: Pt: ^Patient: Ord: CMS Assessment    
            57277-6   Reason For Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? 1..19   
       69331-7   Data items collected at inpatient facility admission or agency discharge only    
            57198-4   Intervention Synopsis:    
                 57270-1   Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care    
                 57271-9   Falls prevention interventions    
                 57272-7   Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment    
                 57273-5   Intervention(s) to monitor and mitigate pain    
                 57274-3   Plan of care includes intervention to prevent pressure injuries [CMS Assessment]Plan of care includes intervention to prevent pressure injuries [CMS Assessment]Plan of care includes intervention to prevent pressure injuries: Find: Pt: ^Patient: Ord: CMS Assessment    
                 57275-0   Pressure ulcer treatment based on principles of moist wound healing    
            46578-1   To which Inpatient Facility has the patient been admitted?    
            55128-3   Discharge dispositionDischarge dispositionDischarge disposition: Type: Pt: ^Patient: Nom:    
            46581-5   Date of last (most recent) home visit:   {mm/dd/yyyy} 
            46582-3   Discharge/Transfer/Death Date:   {mm/dd/yyyy} 
 

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Outcome and assessment information set (OASIS) form - version C - Discharge from agency  Pt  ^Patient 
  Long Common Name:  Outcome and assessment information set (OASIS) form - version C - Discharge from agency

FORM DATA DESCRIPTION
  Description: The OASIS is a core set of screening and assessment elements, including standardized definitions and coding categories that form the foundation of the comprehensive assessment for all clients of home health agencies certified to participate in the Medicare or Medicaid program. OASIS-C is a modification to the Outcome and Assessment Information Set (OASIS) that Home Health Agencies (HHAs) must collect in order to participate in the Medicare program. Implementation of OASIS-C, OMB #0938-0760, is required effective January 1, 2010.
 
 

TERM DEFINITION/DESCRIPTION(S)
  The OASIS is a core set of screening and assessment elements, including standardized definitions and coding categories that form the foundation of the comprehensive assessment for all clients of home health agencies certified to participate in the Medicare or Medicaid program. OASIS-C is a modification to the Outcome and Assessment Information Set (OASIS) that Home Health Agencies (HHAs) must collect in order to participate in the Medicare program. Implementation of OASIS-C, OMB #0938-0760, is required effective January1, 2010.
 
 

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.OASIS/Survey
  Panel Type: Panel
  First Released in Version: 2.29
  Last Updated in Version: 2.29
  Status: Active

PARTS

Part Type    Part No.  Part Name   
Component   LP97313-8  Outcome and assessment information set (OASIS) form - version C - Discharge from agency 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Disch Pan Point in time
  Form version Panel Random
  OASIS-C PANEL.SURVEY.OASIS Survey
  OASIS-C - Discharge from agency Panl Survey.OASIS
  Outcome and assessment information set Pnl  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:17 PM
  Attachment Units Required: N
  Long Common Name: Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  Fully Specified Name: Outcome and assessment information set (OASIS) form - version C - Discharge from agency: -: Pt: ^Patient: -:
     
  Component Word Count: 12
  ID: 51824
  # of Panel Elements: 110
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



57040-8   Clinical Record Items [CMS Assessment]Clinical Record Items [CMS Assessment]Clinical record items: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Clinical record items  Pt  ^Patient  CMS Assessment
  Long Common Name:  Clinical Record Items [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Subset
  Status: Active.
Change Reason: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP96866-6  Clinical record items 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Point in time
  Pan Panl Random
  Panel Pnl Survey

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:17 PM
  Attachment Units Required: N
  Long Common Name: Clinical Record Items [CMS Assessment]
  Fully Specified Name: Clinical record items: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 3
  ID: 51662
  Status (Raw): ACTIVE


46500-5   Discipline of Person Completing Assessment Provider [CMS Assessment]Discipline of Person Completing Assessment Provider [CMS Assessment]Discipline of person completing assessment: Type: Pt: Provider: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Discipline of person completing assessment  Type  Pt  Provider  Nom  CMS Assessment
  Override Display Name for Form:  Discipline of Person Completing Assessment
  Long Common Name:  Discipline of Person Completing Assessment Provider [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  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).
 
 

OBSERVATION ID IN FORM
M0080

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL245-2)  
 
Source: 
  SEQ#        Answer        Code         Answer ID    
  1       RN       1       LA6367-2  
  2       PT       2       LA6353-2  
  3       SLP/ST       3       LA6378-9  
  4       OT       4       LA6309-4  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  46462-8 Outcome and assessment information set (OASIS) form - version B1
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
  86261-5 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88370-2 Outcome and assessment information set (OASIS) form - version D - Discharged from agency - death at home [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP74749-0  Discipline of person completing assessment 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP7504-6  Provider 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP91379-5  Person 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Typ
  Nominal Random  
  Persons Survey  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0080     D 
   CMS OASIS   M0080     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:17 PM
  Attachment Units Required: N
  Long Common Name: Discipline of Person Completing Assessment Provider [CMS Assessment]
  Fully Specified Name: Discipline of person completing assessment: Type: Pt: Provider: Nom: CMS Assessment
     
  Component Word Count: 5
  ID: 38414
  Status (Raw): ACTIVE


46501-3   Date assessment information completed [CMS Assessment]Date assessment information completed [CMS Assessment]Date assessment information completed: Date: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Date assessment information completed  Date  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Date Assessment Completed
  Long Common Name:  Date assessment information completed [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

OBSERVATION ID IN FORM
M0090

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  46462-8 Outcome and assessment information set (OASIS) form - version B1
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  62812-3 PhenX domain - Physical activity and physical fitness
  62863-6 PhenX domain - Infectious diseases and immunity
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
  86261-5 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88370-2 Outcome and assessment information set (OASIS) form - version D - Discharged from agency - death at home [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP74694-8  Date assessment information completed 
Property   LP182451-7  Date 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Quan Random
  Point in time Quant Survey
  QNT Quantitative  

EXAMPLE UNITS
  Unit  Source Type
  {mm/dd/yyyy}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {mm/dd/yyyy} 

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0090     C2 
   CMS OASIS   M0090     D 
   https://www.phenxtoolkit.org   PX150801290101   PX150801_Diary_Day1_Date_Month   
   https://www.phenxtoolkit.org   PX150801290102   PX150801_Diary_Day1_Date_Day   
   https://www.phenxtoolkit.org   PX150801290103   PX150801_Diary_Day1_Date_Year   
   https://www.phenxtoolkit.org   PX150801300101   PX150801_Diary_Day2_Date_Month   
   https://www.phenxtoolkit.org   PX150801300102   PX150801_Diary_Day2_Date_Day   
   https://www.phenxtoolkit.org   PX150801300103   PX150801_Diary_Day2_Date_Year   
   https://www.phenxtoolkit.org   PX150801310101   PX150801_Diary_Day3_Date_Month   
   https://www.phenxtoolkit.org   PX150801310102   PX150801_Diary_Day3_Date_Day   
   https://www.phenxtoolkit.org   PX150801310103   PX150801_Diary_Day3_Date_Year   
   https://www.phenxtoolkit.org   PX150801320101   PX150801_Diary_Day4_Date_Month   
   https://www.phenxtoolkit.org   PX150801320102   PX150801_Diary_Day4_Date_Day   
   https://www.phenxtoolkit.org   PX150801320103   PX150801_Diary_Day4_Date_Year   
   https://www.phenxtoolkit.org   PX150801330101   PX150801_Diary_Day5_Date_Month   
   https://www.phenxtoolkit.org   PX150801330102   PX150801_Diary_Day5_Date_Day   
   https://www.phenxtoolkit.org   PX150801330103   PX150801_Diary_Day5_Date_Year   
   https://www.phenxtoolkit.org   PX150801340101   PX150801_Diary_Day6_Date_Month   
   https://www.phenxtoolkit.org   PX150801340102   PX150801_Diary_Day6_Date_Day   
   https://www.phenxtoolkit.org   PX150801340103   PX150801_Diary_Day6_Date_Year   
   https://www.phenxtoolkit.org   PX150801350101   PX150801_Diary_Day7_Date_Month   
   https://www.phenxtoolkit.org   PX150801350102   PX150801_Diary_Day7_Date_Day   
   https://www.phenxtoolkit.org   PX150801350103   PX150801_Diary_Day7_Date_Year   
   https://www.phenxtoolkit.org   PX161201030100   PX161201_Date_Month   
   https://www.phenxtoolkit.org   PX161201030200   PX161201_Date_Day   
   https://www.phenxtoolkit.org   PX161201030300   PX161201_Date_Year   
   https://www.phenxtoolkit.org   PX161201040000   PX161201_Country_Of_Birth   

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:17 PM
  Attachment Units Required: N
  Long Common Name: Date assessment information completed [CMS Assessment]
  Fully Specified Name: Date assessment information completed: Date: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 4
  ID: 38415
  Status (Raw): ACTIVE


57200-8   Reason for assessment [CMS Assessment]Reason for assessment [CMS Assessment]Reason for assessment: Find: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Reason for assessment  Find  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  This Assessment is Currently Being Completed for the Following Reason:
  Long Common Name:  Reason for assessment [CMS Assessment]

OBSERVATION ID IN FORM
M0100

SKIP LOGIC
If Yes to "4 - Recertification (follow-up reassessment" , then go to M0110. If Yes to "5 - Other follow-up", then go to M0110. If Yes to "6 - Transferred to an inpatient facility - patient not discharged from agency", then go to M1040. If Yes to"7 - Transferred to an inpatient facility - patient discharged from agency", then go to M1040. If "Yes to 8 - Death at home", then go to M0903. If " Yes to 9 - Discharge from agency", then go to M1040.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL773-3)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Start of care - further visits planned       1       LA6390-4  
  2       Resumption of care (after inpatient stay)       3       LA6366-4  
  3       Recertification (follow-up) reassessment       4       LA6355-7  
  4       Other follow-up       5       LA6312-8  
  5       Transferred to an inpatient facility - patient not discharged from agency       6       LA6402-7  
  6       Transferred to an inpatient facility - patient discharged from agency       7       LA6401-9  
  7       Death at home       8       LA6179-1  
  8       Discharge from agency       9       LA6184-1  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
  86261-5 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88370-2 Outcome and assessment information set (OASIS) form - version D - Discharged from agency - death at home [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75490-0  Reason for assessment 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Nominal Survey
  Finding Point in time  
  Findings Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0100     D 
   CMS OASIS   M0100     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:17 PM
  Attachment Units Required: N
  Long Common Name: Reason for assessment [CMS Assessment]
  Fully Specified Name: Reason for assessment: Find: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 3
  ID: 51830
  Status (Raw): ACTIVE


57201-6   Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment]Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment]Date of Physician-ordered Start of Care (Resumption of Care): Date: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Date of Physician-ordered Start of Care (Resumption of Care)  Date  Pt  ^Patient  Qn  CMS Assessment
  Long Common Name:  Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97134-8  Date of Physician-ordered Start of Care (Resumption of Care) 
Property   LP182451-7  Date 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21371-7  Start 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Quan Random
  Point in time Quant Started
  QNT Quantitative Survey

EXAMPLE UNITS
  Unit  Source Type
  {mm/dd/yyyy}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {mm/dd/yyyy} 

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0102     D 
   CMS OASIS   M0102     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:17 PM
  Attachment Units Required: N
  Long Common Name: Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment]
  Fully Specified Name: Date of Physician-ordered Start of Care (Resumption of Care): Date: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 10
  ID: 51831
  Status (Raw): ACTIVE


57202-4   Date of ReferralDate of ReferralDate of Referral: Date: Pt: ^Patient: Qn:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Date of Referral  Date  Pt  ^Patient  Qn 
  Long Common Name:  Date of Referral

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from CMS assessment to method-less since this is a general concept and not specific to CMS assessments.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86636-8 Family planning report - FPAR 2.0 set
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97188-4  Date of Referral 
Property   LP182451-7  Date 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 

RELATED NAMES
  Point in time Quant Survey
  QNT Quantitative  
  Quan Random  

EXAMPLE UNITS
  Unit  Source Type
  {mm/dd/yyyy}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {mm/dd/yyyy} 

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0104     D 
   CMS OASIS   M0104     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Date of Referral
  Fully Specified Name: Date of Referral: Date: Pt: ^Patient: Qn:
     
  Component Word Count: 3
  ID: 51832
  Status (Raw): ACTIVE


57203-2   Episode Timing [CMS Assessment]Episode Timing [CMS Assessment]Episode Timing: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Episode Timing  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?
  Long Common Name:  Episode Timing [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: 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 for consistent modeling across CMS forms.

NORMATIVE ANSWER LIST    (LL774-1)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Early       1       LA12111-3  
  2       Later       2       LA12112-1  
  3       Unknown
http://snomed.info/sct ©: 261665006 Unknown (qualifier value)    
  UK       LA4489-6  
  4       Not Applicable: No Medicare case mix group to be defined by this assessment.       NA       LA12114-7  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97189-2  Episode Timing 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0110     D 
   CMS OASIS   M0110     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Episode Timing [CMS Assessment]
  Fully Specified Name: Episode Timing: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 2
  ID: 51833
  Status (Raw): ACTIVE


69328-3   Patient history and diagnosis - transfer to facility, discharge from agency [OASIS-C]Patient history and diagnosis - transfer to facility, discharge from agency [OASIS-C]Patient history and diagnosis - transfer to facility, discharge from agency: -: Pt: ^Patient: -: OASIS-C  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Patient history and diagnosis - transfer to facility, discharge from agency  Pt  ^Patient  OASIS-C
  Override Display Name for Form:  Patient history and diagnosis
  Long Common Name:  Patient history and diagnosis - transfer to facility, discharge from agency [OASIS-C]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.OASIS/Survey
  Panel Type: Panel
  First Released in Version: 2.38
  Last Updated in Version: 2.44
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP135990-2  Patient history and diagnosis - transfer to facility, discharge from agency 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP97133-0  OASIS-C 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP91302-7  History 
Fragments for synonyms   LP21059-8  Panel 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  Disch PANEL.SURVEY.OASIS Random
  Dx Panl Survey
  Hx Patient Hx Survey.OASIS
  Outcome and assessment information set Patient hx & Dx - transfer to facility, d/c  
  Pan Pnl  
  Panel Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Patient history and diagnosis - transfer to facility, discharge from agency [OASIS-C]
  Fully Specified Name: Patient history and diagnosis - transfer to facility, discharge from agency: -: Pt: ^Patient: -: OASIS-C
     
  Component Word Count: 10
  ID: 68639
  Status (Raw): ACTIVE


57208-1   Influenza vaccination received in Reporting Period [CMS Assessment]Influenza vaccination received in Reporting Period [CMS Assessment]Influenza virus vaccination received: Find: RptPeriod: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Influenza virus vaccination received  Find  RptPeriod  ^Patient  Ord  CMS Assessment
  Long Common Name:  Influenza vaccination received in Reporting Period [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Identifies whether the patient received an influenza vaccine for this year’s flu season
 
 

OBSERVATION ID IN FORM
M1040

FORM CONTEXT
Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year's influenza season (October 1 through March 31) during this episode of care?

SKIP LOGIC
If "1 - Yes", then go to M1050. If "NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season", then go to M1050.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.64
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: 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 for consistent modeling across CMS forms; Added "vaccination received" to the Component for consistent modeling across LOINC vaccination terms.; Added "virus" to Component to be consistent with other "Influenza virus" terms.

NORMATIVE ANSWER LIST    (LL780-8)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       No
http://snomed.info/sct ©: 373067005 No (qualifier value)    
  0       LA32-8  
  2       Yes
http://snomed.info/sct ©: 373066001 Yes (qualifier value)    
  1       LA33-6  
  3       Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season.       NA       LA12150-1  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  57039-0 Outcome and assessment information set (OASIS) form - version C LL780-8 NORMATIVE 3
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility LL780-8 NORMATIVE 3
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL780-8 NORMATIVE 3
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment] LL4495-9 NORMATIVE 8
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4495-9 NORMATIVE 8
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment] LL4495-9 NORMATIVE 8
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4495-9 NORMATIVE 8
  

MEMBER OF THESE EQUIVALENCE GROUPS
  LG32757-3  Influenza virus

PARTS

Part Type    Part No.  Part Name   
Component   LP156336-2  Influenza virus vaccination received 
Property   LP6813-2  Find   [Finding] 
Time   LP190654-6  RptPeriod   [Reporting Period] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Influenza vacc received Screen
  Finding Ordinal Survey
  Findings QL  
  FLUV Qual  
  Influ Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1046     D 
   CMS OASIS   M1046     C2 

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Influenza vaccination received in Reporting Period [CMS Assessment]
  Fully Specified Name: Influenza virus vaccination received: Find: RptPeriod: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 4
  ID: 51839
  Status (Raw): ACTIVE


57209-9   Reason influenza virus vaccine not received [OASIS-C]Reason influenza virus vaccine not received [OASIS-C]Reason influenza virus vaccine not received: Find: Pt: ^Patient: Nom: OASIS-C  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Reason influenza virus vaccine not received  Find  Pt  ^Patient  Nom  OASIS-C
  Long Common Name:  Reason influenza virus vaccine not received [OASIS-C]

OBSERVATION ID IN FORM
M1045

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.44
  Status: Active

NORMATIVE ANSWER LIST    (LL781-6)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Received from another health care provider (e.g., physician)       1       LA12151-9  
  2       Received from your agency previously during this year's flu season       2       LA12152-7  
  3       Offered and declined       3       LA186-9  
  4       Assessed and determined to have medical contraindication(s)       4       LA12154-3  
  5       Not indicated; patient does not meet age/condition guidelines for influenza vaccine       5       LA12155-0  
  6       Inability to obtain vaccine due to declared shortage       6       LA12156-8  
  7       None of the above       7       LA9-3  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75497-5  Reason influenza virus vaccine not received 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP97133-0  OASIS-C 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  Finding Nominal Survey
  Findings Outcome and assessment information set Survey.OASIS
  FLUV Point in time  
  Influ Random  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Reason influenza virus vaccine not received [OASIS-C]
  Fully Specified Name: Reason influenza virus vaccine not received: Find: Pt: ^Patient: Nom: OASIS-C
     
  Component Word Count: 6
  ID: 51840
  Status (Raw): ACTIVE


57210-7   Pneumococcal vaccine [OASIS-C]Pneumococcal vaccine [OASIS-C]Pneumococcal vaccine: Find: Pt: ^Patient: Ord: OASIS-C  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Pneumococcal vaccine  Find  Pt  ^Patient  Ord  OASIS-C
  Long Common Name:  Pneumococcal vaccine [OASIS-C]

OBSERVATION ID IN FORM
M1050

SKIP LOGIC
If "1 - Yes", then go to M1500 at TRN, go to M1230 at DC.

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.44
  Status: Active

NORMATIVE ANSWER LIST    (LL251-0)  
 
Source: Regenstrief LOINC
  SEQ#        Answer        Code         Answer ID    
  1       No
http://snomed.info/sct ©: 373067005 No (qualifier value)    
  0       LA32-8  
  2       Yes
http://snomed.info/sct ©: 373066001 Yes (qualifier value)    
  1       LA33-6  

SURVEY QUESTION
Text: Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?
Source: OASIS-C.M1050

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75394-4  Pneumococcal vaccine 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP97133-0  OASIS-C 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  Finding QL Survey
  Findings Qual Survey.OASIS
  Ordinal Qualitative  
  Outcome and assessment information set Random  
  Point in time Screen  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Pneumococcal vaccine [OASIS-C]
  Fully Specified Name: Pneumococcal vaccine: Find: Pt: ^Patient: Ord: OASIS-C
     
  Component Word Count: 2
  ID: 51841
  Status (Raw): ACTIVE


57211-5   Reason pneumococcal vaccine not given [OASIS-C]Reason pneumococcal vaccine not given [OASIS-C]Reason pneumococcal vaccine not given: Find: Pt: ^Patient: Nom: OASIS-C  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Reason pneumococcal vaccine not given  Find  Pt  ^Patient  Nom  OASIS-C
  Override Display Name for Form:  Reason PPV not received:
  Long Common Name:  Reason pneumococcal vaccine not given [OASIS-C]

OBSERVATION ID IN FORM
M1055

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.48
  Status: Active

NORMATIVE ANSWER LIST    (LL782-4)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Patient has received PPV in the past       1       LA12158-4  
  2       Offered and declined       2       LA186-9  
  3       Assessed and determined to have medical contraindication(s)       3       LA12154-3  
  4       Not indicated; patient does not meet age/condition guidelines for PPV       4       LA12161-8  
  5       None of the above       5       LA9-3  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97139-7  Reason pneumococcal vaccine not given 
Component   LP97320-3  Reason pneumococcal vaccine not 
     Suffix   LP29256-2  given 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP97133-0  OASIS-C 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  Finding Nominal Random
  Findings Outcome and assessment information set Survey
  Gvn Point in time Survey.OASIS

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Reason pneumococcal vaccine not given [OASIS-C]
  Fully Specified Name: Reason pneumococcal vaccine not given: Find: Pt: ^Patient: Nom: OASIS-C
     
  Component Word Count: 5
  ID: 51842
  Status (Raw): ACTIVE


57042-4   Sensory status [CMS Assessment]Sensory status [CMS Assessment]Sensory status: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Sensory status  Pt  ^Patient  CMS Assessment
  Long Common Name:  Sensory status [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Subset
  Status: Active.
Change Reason: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP96868-2  Sensory status 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Point in time
  Pan Panl Random
  Panel Pnl Survey

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Sensory status [CMS Assessment]
  Fully Specified Name: Sensory status: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 2
  ID: 51665
  Status (Raw): ACTIVE


57215-6   Vision [CMS Assessment]Vision [CMS Assessment]Vision: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Vision  Find  Pt  ^Patient  Ord  CMS Assessment
  Long Common Name:  Vision [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL784-0)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Normal vision: sees adequately in most situations; can see medication labels, newsprint.       0       LA12168-3  
  2       Partially impaired: cannot see medication labels or newsprint, but can see obstacles in path, and the surrounding layout; can count fingers at arm's length.       1       LA12169-1  
  3       Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive.       2       LA6375-5  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75855-4  Vision 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1200     D 
   CMS OASIS   M1200     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Vision [CMS Assessment]
  Fully Specified Name: Vision: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 1
  ID: 51846
  Status (Raw): ACTIVE


57216-4   Ability to hear [CMS Assessment]Ability to hear [CMS Assessment]Ability to hear: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Ability to hear  Find  Pt  ^Patient  Ord  CMS Assessment
  Long Common Name:  Ability to hear [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL785-7)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Adequate: hears normal conversation without difficulty.       0       LA12123-8  
  2       Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.       1       LA12124-6  
  3       Severely Impaired: absence of useful hearing.       2       LA12125-3  
  4       Unable to assess hearing.       UK       LA12174-1  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP98015-8  Ability to hear 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1210     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:18 PM
  Attachment Units Required: N
  Long Common Name: Ability to hear [CMS Assessment]
  Fully Specified Name: Ability to hear: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 3
  ID: 51848
  Status (Raw): ACTIVE


57217-2   Understanding of verbal content [CMS Assessment]Understanding of verbal content [CMS Assessment]Understanding of verbal content: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Understanding of verbal content  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Understanding of verbal content in patient's own language (with hearing aid or device if used)
  Long Common Name:  Understanding of verbal content [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL786-5)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Understands: clear comprehension without cues or repetitions.       0       LA12175-8  
  2       Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.       1       LA12176-6  
  3       Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.       2       LA12177-4  
  4       Rarely/never understands.       3       LA27670-1  
  5       Unable to assess understanding.       UK       LA12179-0  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP98016-6  Understanding of verbal content 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1220     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Understanding of verbal content [CMS Assessment]
  Fully Specified Name: Understanding of verbal content: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 4
  ID: 51849
  Status (Raw): ACTIVE


57218-0   Speech and oral expression of language [CMS Assessment]Speech and oral expression of language [CMS Assessment]Speech and oral expression of language: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Speech and oral expression of language  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Speech and oral (verbal) expression of language (in patient's own language)
  Long Common Name:  Speech and oral expression of language [CMS Assessment]

OBSERVATION ID IN FORM
M1230

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL787-3)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.       0       LA6197-3  
  2       Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional errors in word choice, grammar or speech intelligibility; needs minimal prompting or assistance).       1       LA12181-6  
  3       Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.       2       LA12182-4  
  4       Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener. Speech limited to single words or short phrases.       3       LA12183-2  
  5       Unable to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (for example, speech is nonsensical or unintelligible).       4       LA12184-0  
  6       Patient nonresponsive or unable to speak.       5       LA6336-7  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP98017-4  Speech and oral expression of language 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1230     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Speech and oral expression of language [CMS Assessment]
  Fully Specified Name: Speech and oral expression of language: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51850
  Status (Raw): ACTIVE


57219-8   Formal pain assessment using standardized tool [CMS Assessment]Formal pain assessment using standardized tool [CMS Assessment]Formal pain assessment using standardized tool: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Formal pain assessment using standardized tool  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient’s ability to communicate the severity of pain)?
  Long Common Name:  Formal pain assessment using standardized tool [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: 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 for consistent modeling across CMS forms.

NORMATIVE ANSWER LIST    (LL788-1)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       No standardized, validated assessment conducted       0       LA27671-9  
  2       Yes, and it does not indicate severe pain       1       LA12187-3  
  3       Yes, and it indicates severe pain       2       LA12188-1  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97194-2  Formal pain assessment using standardized tool 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1240     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Formal pain assessment using standardized tool [CMS Assessment]
  Fully Specified Name: Formal pain assessment using standardized tool: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51851
  Status (Raw): ACTIVE


57220-6   Frequency of pain interfering with activity or movement [CMS Assessment]Frequency of pain interfering with activity or movement [CMS Assessment]Frequency of pain interfering with activity or movement: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Frequency of pain interfering with activity or movement  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Frequency of pain interfering with patient's activity or movement:
  Long Common Name:  Frequency of pain interfering with activity or movement [CMS Assessment]

OBSERVATION ID IN FORM
M1242

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed Property to NRat because this is a frequency term; Changed Property from NRat to Find because the answer list does not reflect Nrat.

NORMATIVE ANSWER LIST    (LL789-9)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  0       Patient has no pain       0       LA12189-9  
  1       Patient has pain that does not interfere with activity or movement       1       LA12190-7  
  2       Less often than daily       2       LA6249-2  
  3       Daily, but not constantly       3       LA6177-5  
  4       All of the time       4       LA6154-4  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP98018-2  Frequency of pain interfering with activity or movement 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21325-3  Activity 

RELATED NAMES
  Activ Movements Qualitative
  Actvty Ordinal Random
  Centers for Medicare and Medicaid Assessment Point in time Screen
  Finding QL Survey
  Findings Qual  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1242     D 
   CMS OASIS   M1242     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Frequency of pain interfering with activity or movement [CMS Assessment]
  Fully Specified Name: Frequency of pain interfering with activity or movement: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 8
  ID: 51852
  Status (Raw): ACTIVE


57044-0   Integumentary statusIntegumentary statusIntegumentary status: -: Pt: ^Patient: -:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Integumentary status  Pt  ^Patient 
  Long Common Name:  Integumentary status

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  Panel Type: Panel
  First Released in Version: 2.29
  Last Updated in Version: 2.29
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP96882-3  Integumentary status 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  Outcome and assessment information set Survey  
  Point in time Survey.OASIS  
  Random    

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Integumentary status
  Fully Specified Name: Integumentary status: -: Pt: ^Patient: -:
     
  Component Word Count: 2
  ID: 51667
  Status (Raw): ACTIVE


57307-1   Unhealed pressure injury at stage 2 or higher or designated as unstageable [OASIS-C]Unhealed pressure injury at stage 2 or higher or designated as unstageable [OASIS-C]Unhealed pressure injury at Stage 2 or higher or designated as unstageable: Find: Pt: ^Patient: Nom: OASIS-C  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Unhealed pressure injury at Stage 2 or higher or designated as unstageable  Find  Pt  ^Patient  Nom  OASIS-C
  Long Common Name:  Unhealed pressure injury at stage 2 or higher or designated as unstageable [OASIS-C]

OBSERVATION ID IN FORM
M1306

SKIP LOGIC
If "0 - No", then go to M1322.

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.64
  Status: Active.
Change Reason: "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL251-0)  
 
Source: Regenstrief LOINC
  SEQ#        Answer        Code         Answer ID    
  1       No
http://snomed.info/sct ©: 373067005 No (qualifier value)    
  0       LA32-8  
  2       Yes
http://snomed.info/sct ©: 373066001 Yes (qualifier value)    
  1       LA33-6  

SURVEY QUESTION
Text: Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"
Source: OASIS-C.M1306

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263729-8  Unhealed pressure injury at stage 2 or higher or designated as unstageable 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP97133-0  OASIS-C 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 
Fragments for synonyms   LP57601-4  As 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  Arterial Stenosis Outcome and assessment information set Random
  Finding Point in time Survey
  Findings pressure injury Survey.OASIS
  II Pressure ulcer Ulcer
  Nominal Pressure Ulcers  

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Unhealed pressure injury at stage 2 or higher or designated as unstageable [OASIS-C]
  Fully Specified Name: Unhealed pressure injury at Stage 2 or higher or designated as unstageable: Find: Pt: ^Patient: Nom: OASIS-C
     
  Component Word Count: 12
  ID: 51949
  Status (Raw): ACTIVE


57222-2   Oldest non-epithelialized stage 2 pressure injury present at discharge [CMS Assessment]Oldest non-epithelialized stage 2 pressure injury present at discharge [CMS Assessment]Oldest non-epithelialized stage 2 pressure injury present at discharge: Find: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Oldest non-epithelialized stage 2 pressure injury present at discharge  Find  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Oldest non-epithelialized stage II pressure ulcer that is present at discharge
  Long Common Name:  Oldest non-epithelialized stage 2 pressure injury present at discharge [CMS Assessment]

OBSERVATION ID IN FORM
M1307

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL828-5)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Was present at the most recent SOC/ROC assessment       1       LA12403-4  
  2       Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified: __ __ /__ __ /____ __ __       2       LA12404-2  
  3       No non-epithelialized Stage II pressure ulcers are present at discharge       NA       LA12405-9  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  57039-0 Outcome and assessment information set (OASIS) form - version C LL828-5 NORMATIVE 3
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL828-5 NORMATIVE 3
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4716-8 NORMATIVE 3
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4716-8 NORMATIVE 3
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263852-8  Oldest non-epithelialized stage 2 pressure injury present at discharge 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Nominal Random
  Disch Point in time Survey
  Finding pressure injury Ulcer
  Findings Pressure ulcer  
  II Pressure Ulcers  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1307     D 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Oldest non-epithelialized stage 2 pressure injury present at discharge [CMS Assessment]
  Fully Specified Name: Oldest non-epithelialized stage 2 pressure injury present at discharge: Find: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 10
  ID: 51854
  Status (Raw): ACTIVE


58052-2   Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment]Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment]Date pressure injury first identified: Date: Pt: Pressure injury.oldest non-epithelialized stage 2: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Date pressure injury first identified  Date  Pt  Pressure injury.oldest non-epithelialized stage 2  Qn  CMS Assessment
  Long Common Name:  Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP265004-4  Date pressure injury first identified 
Component   LP265006-9  Date pressure injury first 
     Suffix   LP29257-0  identified 
Property   LP182451-7  Date 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP263847-8  Pressure injury.oldest non-epithelialized stage 2 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Pressure ulcer Quantitative
  II Pressure Ulcers Random
  Isolated QNT Survey
  Point in time Quan Ulcer
  pressure injury Quant  

EXAMPLE UNITS
  Unit  Source Type
  {mm/dd/yyyy}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {mm/dd/yyyy} 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment]
  Fully Specified Name: Date pressure injury first identified: Date: Pt: Pressure injury.oldest non-epithelialized stage 2: Qn: CMS Assessment
     
  Component Word Count: 5
  ID: 52794
  Status (Raw): ACTIVE


58102-5   Current number of unhealed (non-epithelialized) pressure injuries at each stage [OASIS-C]Current number of unhealed (non-epithelialized) pressure injuries at each stage [OASIS-C]Current number of unhealed (non-epithelialized) pressure injuries at each stage: -: Pt: ^Patient: -: OASIS-C  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Current number of unhealed (non-epithelialized) pressure injuries at each stage  Pt  ^Patient  OASIS-C
  Override Display Name for Form:  Current number of unhealed (non-epithelialized) pressure ulcers at each stage
  Long Common Name:  Current number of unhealed (non-epithelialized) pressure injuries at each stage [OASIS-C]

OBSERVATION ID IN FORM
M1308

FORM CODING INSTRUCTIONS
Enter “0” if none; excludes Stage I pressure ulcers

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  Panel Type: Panel
  First Released in Version: 2.29
  Last Updated in Version: 2.64
  Status: Active.
Change Reason: "Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP89807-9  Current number of unhealed (non-epithelialized) pressure injuries at each stage 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP97133-0  OASIS-C 
Fragments for synonyms   LP266931-7  Pressure injuries 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  No Point in time Random
  Num Pressure ulcer Survey
  Outcome and assessment information set Pressure Ulcers Survey.OASIS

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Current number of unhealed (non-epithelialized) pressure injuries at each stage [OASIS-C]
  Fully Specified Name: Current number of unhealed (non-epithelialized) pressure injuries at each stage: -: Pt: ^Patient: -: OASIS-C
     
  Component Word Count: 11
  ID: 52849
  Status (Raw): ACTIVE


57186-9   Number of pressure injuries at each stage SetNumber of pressure injuries at each stage SetNumber of pressure injuries at each stage: -: Pt: ^Patient: Set:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries at each stage  Pt  ^Patient  Set 
  Override Display Name for Form:  Number currently present
  Long Common Name:  Number of pressure injuries at each stage Set

OBSERVATION ID IN FORM
M1308.1

FORM CODING INSTRUCTIONS
Column 1 Complete at SOC/ROC/FU & D/C.

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  Panel Type: Panel
  First Released in Version: 2.29
  Last Updated in Version: 2.64
  Status: Active.
Change Reason: "Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75240-9  Number of pressure injuries at each stage 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7754-7  Set 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  No Point in time Random
  Num Pressure ulcer Survey
  Outcome and assessment information set Pressure Ulcers Survey.OASIS

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries at each stage Set
  Fully Specified Name: Number of pressure injuries at each stage: -: Pt: ^Patient: Set:
     
  Component Word Count: 7
  ID: 51815
  Status (Raw): ACTIVE


55124-2   Number of pressure injuries - stage 2 [CMS Assessment]Number of pressure injuries - stage 2 [CMS Assessment]Number of pressure injuries - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 2  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
  Long Common Name:  Number of pressure injuries - stage 2 [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 2 pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.
 
 

OBSERVATION ID IN FORM
M1308.1a

FORM CONTEXT
Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263748-8  Number of pressure injuries - stage 2 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  II Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300B1     2.0 
   CMS IRF-PAI   M0300B1     3.0 
   CMS IRF-PAI   M0300B1     1.5 
   CMS IRF-PAI   M0300B1     1.4 
   CMS LCDS   M0300B1     3.00 
   CMS LCDS   M0300B1     4.00 
   CMS MDS   M0300B1     1.16.1 
   CMS MDS   M0300B1     1.15.1 
   CMS MDS   M0300B1     1.14.1 
   CMS MDS   M0300B1     1.17.1 
   CMS OASIS   M1311A1     D 
   CMS OASIS   M1311A1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 2 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 6
  ID: 49485
  Status (Raw): ACTIVE


55125-9   Number of pressure injuries - stage 3 [CMS Assessment]Number of pressure injuries - stage 3 [CMS Assessment]Number of pressure injuries - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 3  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
  Long Common Name:  Number of pressure injuries - stage 3 [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 3 pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
 
 

OBSERVATION ID IN FORM
M1308.1b

FORM CONTEXT
Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

SKIP LOGIC
If 0, skip to M0400C, Stage 4.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263749-6  Number of pressure injuries - stage 3 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  III Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300C1     2.0 
   CMS IRF-PAI   M0300C1     3.0 
   CMS IRF-PAI   M0300C1     1.5 
   CMS IRF-PAI   M0300C1     1.4 
   CMS LCDS   M0300C1     3.00 
   CMS LCDS   M0300C1     4.00 
   CMS MDS   M0300C1     1.16.1 
   CMS MDS   M0300C1     1.15.1 
   CMS MDS   M0300C1     1.14.1 
   CMS MDS   M0300C1     1.17.1 
   CMS OASIS   M1311B1     D 
   CMS OASIS   M1311B1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:19 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 3 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 6
  ID: 49486
  Status (Raw): ACTIVE


55126-7   Number of pressure injuries - stage 4 [CMS Assessment]Number of pressure injuries - stage 4 [CMS Assessment]Number of pressure injuries - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 4  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
  Long Common Name:  Number of pressure injuries - stage 4 [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 4 pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
 
 

OBSERVATION ID IN FORM
M1308.1c

FORM CONTEXT
Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263750-4  Number of pressure injuries - stage 4 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300D1     2.0 
   CMS IRF-PAI   M0300D1     3.0 
   CMS IRF-PAI   M0300D1     1.5 
   CMS IRF-PAI   M0300D1     1.4 
   CMS LCDS   M0300D1     3.00 
   CMS LCDS   M0300D1     4.00 
   CMS MDS   M0300D1     1.16.1 
   CMS MDS   M0300D1     1.15.1 
   CMS MDS   M0300D1     1.14.1 
   CMS MDS   M0300D1     1.17.1 
   CMS OASIS   M1311C1     D 
   CMS OASIS   M1311C1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 4 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 6
  ID: 49487
  Status (Raw): ACTIVE


54893-3   Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]Number of pressure injuries - unstageable due to non-removable dressing or device: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - unstageable due to non-removable dressing or device  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Unstageable: Known or likely but unstageable due to non-removable dressing or device
  Long Common Name:  Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]

FORM DATA DESCRIPTION
  Description: Unstageable: Known or likely but unstageable due to non-removable dressing or device
 
 

TERM DEFINITION/DESCRIPTION(S)
  A pressure ulcer that is unstageable due to a non-removable dressing is defined as a known pressure ulcer that is covered by a non-removable dressing or device, such as a surgical dressing, cast, other orthopedic device, or dressing not to be removed per physician's order.
 
 

OBSERVATION ID IN FORM
M1308.1d1

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt".; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263735-5  Number of pressure injuries - unstageable due to non-removable dressing or device 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300E1     2.0 
   CMS IRF-PAI   M0300E1     3.0 
   CMS IRF-PAI   M0300E1     1.5 
   CMS IRF-PAI   M0300E1     1.4 
   CMS LCDS   M0300E1     3.00 
   CMS LCDS   M0300E1     4.00 
   CMS MDS   M0300E1     1.16.1 
   CMS MDS   M0300E1     1.15.1 
   CMS MDS   M0300E1     1.14.1 
   CMS MDS   M0300E1     1.17.1 
   CMS OASIS   M1311D1     D 
   CMS OASIS   M1311D1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - unstageable due to non-removable dressing or device: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 12
  ID: 49230
  Status (Raw): ACTIVE


54946-9   Number of pressure injuries - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.
  Long Common Name:  Number of pressure injuries - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]

FORM DATA DESCRIPTION
  Description: Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.
 
 

TERM DEFINITION/DESCRIPTION(S)
  Slough tissue is defined as non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Eschar tissue is defined as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike.
 
 

OBSERVATION ID IN FORM
M1308.1d2

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt";Updated COMPONENT from "and or" to "&or" to match convention; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263737-1  Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar   [Number of pressure injuries - unstageable due to coverage of wound bed by slough/eschar] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300F1     2.0 
   CMS IRF-PAI   M0300F1     3.0 
   CMS IRF-PAI   M0300F1     1.5 
   CMS IRF-PAI   M0300F1     1.4 
   CMS LCDS   M0300F1     3.00 
   CMS LCDS   M0300F1     4.00 
   CMS MDS   M0300F1     1.16.1 
   CMS MDS   M0300F1     1.15.1 
   CMS MDS   M0300F1     1.14.1 
   CMS MDS   M0300F1     1.17.1 
   CMS OASIS   M1311E1     D 
   CMS OASIS   M1311E1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 15
  ID: 49287
  Status (Raw): ACTIVE


54950-1   Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - unstageable with suspected deep tissue injury in evolution  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Unstageable: Suspected deep tissue injury in evolution.
  Long Common Name:  Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A pressure ulcer that is unstageable due to deep tissue injury has purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
 
 

OBSERVATION ID IN FORM
M1308.1d3

FORM CONTEXT
Unstageable: Suspected deep tissue injury in evolution.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt"; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263739-7  Number of pressure injuries - unstageable with suspected deep tissue injury in evolution 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT Ulcer
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300G1     2.0 
   CMS IRF-PAI   M0300G1     3.0 
   CMS IRF-PAI   M0300G1     1.5 
   CMS IRF-PAI   M0300G1     1.4 
   CMS LCDS   M0300G1     3.00 
   CMS LCDS   M0300G1     4.00 
   CMS MDS   M0300G1     1.16.1 
   CMS MDS   M0300G1     1.15.1 
   CMS MDS   M0300G1     1.14.1 
   CMS MDS   M0300G1     1.17.1 
   CMS OASIS   M1311F1     D 
   CMS OASIS   M1311F1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 12
  ID: 49291
  Status (Raw): ACTIVE


57187-7   Number of pressure injuries present at admission SetNumber of pressure injuries present at admission SetNumber of pressure injuries present at admission: -: Pt: ^Patient: Set:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present at admission  Pt  ^Patient  Set 
  Override Display Name for Form:  Number of those listed in Column 1 that were present on admission (most recent SOC/ROC)
  Long Common Name:  Number of pressure injuries present at admission Set

OBSERVATION ID IN FORM
M1308.2

FORM CODING INSTRUCTIONS
Column 2 Complete at FU & D/C. Number of those listed in Column 1 that were present on admission (most recent SOC/ROC)

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  Panel Type: Panel
  First Released in Version: 2.29
  Last Updated in Version: 2.64
  Status: Active.
Change Reason: "Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97307-0  Number of pressure injuries present at admission 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7754-7  Set 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  No Point in time Random
  Num Pressure ulcer Survey
  Outcome and assessment information set Pressure Ulcers Survey.OASIS

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present at admission Set
  Fully Specified Name: Number of pressure injuries present at admission: -: Pt: ^Patient: Set:
     
  Component Word Count: 7
  ID: 51816
  Status (Raw): ACTIVE


54886-7   Number of pressure injuries present upon admission/​reentry - stage 2 [CMS Assessment]Number of pressure injuries present upon admission/​reentry - stage 2 [CMS Assessment]Number of pressure injuries present upon admission &or reentry - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - stage 2  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 2 [CMS Assessment]

OBSERVATION ID IN FORM
M1308.2a

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of admission

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263732-2  Number of pressure injuries present upon admission &or reentry - stage 2   [Number of pressure injuries present upon admission/reentry - stage 2] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  II Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300B2     2.0 
   CMS IRF-PAI   M0300B2     3.0 
   CMS IRF-PAI   M0300B2     1.5 
   CMS IRF-PAI   M0300B2     1.4 
   CMS LCDS   M0300B2     3.00 
   CMS LCDS   M0300B2     4.00 
   CMS MDS   M0300B2     1.16.1 
   CMS MDS   M0300B2     1.15.1 
   CMS MDS   M0300B2     1.14.1 
   CMS MDS   M0300B2     1.17.1 
   CMS OASIS   M1311A2     D 
   CMS OASIS   M1311A2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - stage 2 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 11
  ID: 49222
  Status (Raw): ACTIVE


54887-5   Number of pressure injuries present upon admission/​reentry - stage 3 [CMS Assessment]Number of pressure injuries present upon admission/​reentry - stage 3 [CMS Assessment]Number of pressure injuries present upon admission &or reentry - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - stage 3  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 3 [CMS Assessment]

OBSERVATION ID IN FORM
M1308.2b

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of admission

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263733-0  Number of pressure injuries present upon admission &or reentry - stage 3   [Number of pressure injuries present upon admission/reentry - stage 3] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  III Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300C2     2.0 
   CMS IRF-PAI   M0300C2     3.0 
   CMS IRF-PAI   M0300C2     1.5 
   CMS IRF-PAI   M0300C2     1.4 
   CMS LCDS   M0300C2     3.00 
   CMS LCDS   M0300C2     4.00 
   CMS MDS   M0300C2     1.16.1 
   CMS MDS   M0300C2     1.15.1 
   CMS MDS   M0300C2     1.14.1 
   CMS MDS   M0300C2     1.17.1 
   CMS OASIS   M1311B2     D 
   CMS OASIS   M1311B2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - stage 3 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 11
  ID: 49223
  Status (Raw): ACTIVE


54890-9   Number of pressure injuries present upon admission/​reentry - stage 4 [CMS Assessment]Number of pressure injuries present upon admission/​reentry - stage 4 [CMS Assessment]Number of pressure injuries present upon admission &or reentry - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - stage 4  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 4 [CMS Assessment]

OBSERVATION ID IN FORM
M1308.2c

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of admission

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263734-8  Number of pressure injuries present upon admission &or reentry - stage 4   [Number of pressure injuries present upon admission/reentry - stage 4] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300D2     2.0 
   CMS IRF-PAI   M0300D2     3.0 
   CMS IRF-PAI   M0300D2     1.5 
   CMS IRF-PAI   M0300D2     1.4 
   CMS LCDS   M0300D2     3.00 
   CMS LCDS   M0300D2     4.00 
   CMS MDS   M0300D2     1.16.1 
   CMS MDS   M0300D2     1.15.1 
   CMS MDS   M0300D2     1.14.1 
   CMS MDS   M0300D2     1.17.1 
   CMS OASIS   M1311C2     D 
   CMS OASIS   M1311C2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - stage 4 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 11
  ID: 49227
  Status (Raw): ACTIVE


54894-1   Number of pressure injuries present upon admission/​reentry - unstageable due to non-removable dressing [CMS Assessment]Number of pressure injuries present upon admission/​reentry - unstageable due to non-removable dressing [CMS Assessment]Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Unstageable: Known or likely but unstageable due to non-removable dressing or device
  Long Common Name:  Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing [CMS Assessment]

OBSERVATION ID IN FORM
M1308.2d1

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263736-3  Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing   [Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300E2     2.0 
   CMS IRF-PAI   M0300E2     3.0 
   CMS IRF-PAI   M0300E2     1.5 
   CMS IRF-PAI   M0300E2     1.4 
   CMS LCDS   M0300E2     3.00 
   CMS LCDS   M0300E2     4.00 
   CMS MDS   M0300E2     1.16.1 
   CMS MDS   M0300E2     1.15.1 
   CMS MDS   M0300E2     1.14.1 
   CMS MDS   M0300E2     1.17.1 
   CMS OASIS   M1311D2     D 
   CMS OASIS   M1311D2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 15
  ID: 49231
  Status (Raw): ACTIVE


54947-7   Number of pressure injuries present upon admission/​reentry - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries present upon admission/​reentry - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.
  Long Common Name:  Number of pressure injuries present upon admission/reentry - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]

OBSERVATION ID IN FORM
M1308.2d2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of admission

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263738-9  Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar   [Number of pressure injuries present upon admission/reentry - unstageable due to coverage of wound bed by slough/eschar] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300F2     2.0 
   CMS IRF-PAI   M0300F2     3.0 
   CMS IRF-PAI   M0300F2     1.5 
   CMS IRF-PAI   M0300F2     1.4 
   CMS LCDS   M0300F2     3.00 
   CMS LCDS   M0300F2     4.00 
   CMS MDS   M0300F2     1.16.1 
   CMS MDS   M0300F2     1.15.1 
   CMS MDS   M0300F2     1.14.1 
   CMS MDS   M0300F2     1.17.1 
   CMS OASIS   M1311E2     D 
   CMS OASIS   M1311E2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 20
  ID: 49288
  Status (Raw): ACTIVE


54951-9   Number of pressure injuries present upon admission/​reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries present upon admission/​reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Unstageable: Suspected deep tissue injury in evolution.
  Long Common Name:  Number of pressure injuries present upon admission/reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]

OBSERVATION ID IN FORM
M1308.2d3

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263740-5  Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution   [Number of pressure injuries present upon admission/reentry - unstageable with suspected deep tissue injury in evolution] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT Ulcer
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300G2     2.0 
   CMS IRF-PAI   M0300G2     3.0 
   CMS IRF-PAI   M0300G2     1.5 
   CMS IRF-PAI   M0300G2     1.4 
   CMS LCDS   M0300G2     3.00 
   CMS LCDS   M0300G2     4.00 
   CMS MDS   M0300G2     1.16.1 
   CMS MDS   M0300G2     1.15.1 
   CMS MDS   M0300G2     1.14.1 
   CMS MDS   M0300G2     1.17.1 
   CMS OASIS   M1311F2     C2 
   CMS OASIS   M1311F2     D 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 17
  ID: 49292
  Status (Raw): ACTIVE


57188-5   Stage 3 or 4 pressure injury with largest surface dimensionsStage 3 or 4 pressure injury with largest surface dimensionsStage 3 or 4 pressure injury with largest surface dimensions: -: Pt: ^Patient: -:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Stage 3 or 4 pressure injury with largest surface dimensions  Pt  ^Patient 
  Override Display Name for Form:  Stage III and IV pressure ulcer with the largest surface dimension (length x width)
  Long Common Name:  Stage 3 or 4 pressure injury with largest surface dimensions

SKIP LOGIC
If no Stage 3 or Stage 4 pressure ulcers, go to M1320.

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  Panel Type: Panel
  First Released in Version: 2.29
  Last Updated in Version: 2.64
  Status: Active.
Change Reason: "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97308-8  Stage 3 or 4 pressure injury with largest surface dimensions 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP21372-5  Surface 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  III Pressure ulcer Survey
  Outcome and assessment information set Pressure Ulcers Survey.OASIS
  Point in time Random Ulcer
  pressure injury Surf  

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:20 PM
  Attachment Units Required: N
  Long Common Name: Stage 3 or 4 pressure injury with largest surface dimensions
  Fully Specified Name: Stage 3 or 4 pressure injury with largest surface dimensions: -: Pt: ^Patient: -:
     
  Component Word Count: 10
  ID: 51817
  Status (Raw): ACTIVE


57226-3   Longitudinal diameter Pressure injury.largest stage 3 or 4 [OASIS-C]Longitudinal diameter Pressure injury.largest stage 3 or 4 [OASIS-C]Diameter.long: Len: Pt: Pressure injury.largest stage 3 or 4: Qn: OASIS-C  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Diameter.long  Len  Pt  Pressure injury.largest stage 3 or 4  Qn  OASIS-C
  Override Display Name for Form:  Pressure Ulcer Length:
  Long Common Name:  Longitudinal diameter Pressure injury.largest stage 3 or 4 [OASIS-C]

OBSERVATION ID IN FORM
M1310

BASIC ATTRIBUTES
  Class/Type: SURVEY.OASIS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72450-7  Diameter.long 
Property   LP6822-3  Len   [Length] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP263849-4  Pressure injury.largest stage 3 or 4 
Scale   LP7753-9  Qn 
Method   LP97133-0  OASIS-C 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  DIA Point in time Random
  Diam Pressure ulcer Survey
  III Pressure Ulcers Survey.OASIS
  Length QNT Ulcer
  Long diameter Quan  
  Longitudinal diameter Quant  
  Outcome and assessment information set Quantitative  

EXAMPLE UNITS
  Unit  Source Type
  cm  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  cm 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:21 PM
  Attachment Units Required: N
  Long Common Name: Longitudinal diameter Pressure injury.largest stage 3 or 4 [OASIS-C]
  Fully Specified Name: Diameter.long: Len: Pt: Pressure injury.largest stage 3 or 4: Qn: OASIS-C
     
  Component Word Count: 2
  ID: 51859
  Status (Raw): ACTIVE


52729-1   Diameter transverse Pressure injury.largest stage 3 or 4 [CMS Assessment]Diameter transverse Pressure injury.largest stage 3 or 4 [CMS Assessment]Diameter.transverse: Len: Pt: Pressure injury.largest stage 3 or 4: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Diameter.transverse  Len  Pt  Pressure injury.largest stage 3 or 4  Qn  CMS Assessment
  Override Display Name for Form:  Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length
  Long Common Name:  Diameter transverse Pressure injury.largest stage 3 or 4 [CMS Assessment]

OBSERVATION ID IN FORM
M1312

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.26
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Trial – caution, may change.
Change Reason: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  52743-2 Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
  52744-0 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
  52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
  52746-5 Continuity Assessment Record and Evaluation (CARE) tool - Interim
  52748-1 Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  

PARTS

Part Type    Part No.  Part Name   
Component   LP70908-6  Diameter.transverse 
Property   LP6822-3  Len   [Length] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP263849-4  Pressure injury.largest stage 3 or 4 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  DIA Pressure ulcer Random
  Diam Pressure Ulcers Survey
  Diam transverse QNT Ulcer
  III Quan  
  Length Quant  

EXAMPLE UNITS
  Unit  Source Type
  cm  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  cm 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:21 PM
  Attachment Units Required: N
  Long Common Name: Diameter transverse Pressure injury.largest stage 3 or 4 [CMS Assessment]
  Fully Specified Name: Diameter.transverse: Len: Pt: Pressure injury.largest stage 3 or 4: Qn: CMS Assessment
     
  Component Word Count: 2
  ID: 46862
  Status (Raw): TRIAL


57228-9   Depth Pressure injury.largest stage 3 or 4 [CMS Assessment]Depth Pressure injury.largest stage 3 or 4 [CMS Assessment]Depth: Len: Pt: Pressure injury.largest stage 3 or 4: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Depth  Len  Pt  Pressure injury.largest stage 3 or 4  Qn  CMS Assessment
  Override Display Name for Form:  Pressure Ulcer Depth:
  Long Common Name:  Depth Pressure injury.largest stage 3 or 4 [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Depth of same unhealed ulcer or eschar
 
 

OBSERVATION ID IN FORM
M1314

FORM CODING INSTRUCTIONS
Enter 99.9 if the largest ulcer is unstageable and is not eschar

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.OASIS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  52744-0 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
  52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
  52746-5 Continuity Assessment Record and Evaluation (CARE) tool - Interim
  52748-1 Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP18009-8  Depth 
Property   LP6822-3  Len   [Length] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP263849-4  Pressure injury.largest stage 3 or 4 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Pressure ulcer Quantitative
  Dpth Pressure Ulcers Random
  III QNT Survey
  Length Quan Ulcer
  Point in time Quant  

EXAMPLE UNITS
  Unit  Source Type
  cm  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  cm 

RELATED CODES
Code System Code Code Text Code Version
   CMS MDS   M0610C     1.15.1 
   CMS MDS   M0610C     1.14.1 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:21 PM
  Attachment Units Required: N
  Long Common Name: Depth Pressure injury.largest stage 3 or 4 [CMS Assessment]
  Fully Specified Name: Depth: Len: Pt: Pressure injury.largest stage 3 or 4: Qn: CMS Assessment
     
  Component Word Count: 1
  ID: 51861
  Status (Raw): ACTIVE


57229-7   Status of most problematic pressure injury [CMS Assessment]Status of most problematic pressure injury [CMS Assessment]Status of most problematic pressure injury: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Status of most problematic pressure injury  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Status of most problematic (observable) pressure ulcer:
  Long Common Name:  Status of most problematic pressure injury [CMS Assessment]

OBSERVATION ID IN FORM
M1320

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL791-5)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Newly epithelialized       0       LA12197-2  
  2       Fully granulating       1       LA6203-9  
  3       Early/partial granulation       2       LA6193-2  
  4       Not healing       3       LA6300-3  
  5       No observable pressure ulcer       NA       LA6286-4  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263723-1  Status of most problematic pressure injury 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Pressure ulcer Screen
  Finding Pressure Ulcers Survey
  Findings QL Ulcer
  Ordinal Qual  
  Point in time Qualitative  
  pressure injury Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1320     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:21 PM
  Attachment Units Required: N
  Long Common Name: Status of most problematic pressure injury [CMS Assessment]
  Fully Specified Name: Status of most problematic pressure injury: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51862
  Status (Raw): ACTIVE


46536-9   Number of pressure injuries - stage 1 Ord [CMS Assessment]Number of pressure injuries - stage 1 Ord [CMS Assessment]Number of pressure injuries - stage 1: Num: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 1  Num  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Current Number of Stage I Pressure Ulcers:
  Long Common Name:  Number of pressure injuries - stage 1 Ord [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 1 pressure injury is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
 
 

OBSERVATION ID IN FORM
M1322

FORM CODING INSTRUCTIONS
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed SCALE to Ord because this term has a normative answer list; "Pressure ulcer" has been updated to 'pressure injury' according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL269-2)  
 
Source: 
  SEQ#        Answer        Code         Answer ID    
  1       Zero       0       LA6458-9  
  2       One       1       LA6306-0  
  3       Two       2       LA6404-3  
  4       Three       3       LA6395-3  
  5       Four or more       4       LA6200-5  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  46462-8 Outcome and assessment information set (OASIS) form - version B1 LL269-2 NORMATIVE 5
  57039-0 Outcome and assessment information set (OASIS) form - version C LL269-2 NORMATIVE 5
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL269-2 NORMATIVE 5
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL269-2 NORMATIVE 5
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up LL269-2 NORMATIVE 5
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL269-2 NORMATIVE 5
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL792-3 NORMATIVE 5
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL792-3 NORMATIVE 5
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL792-3 NORMATIVE 5
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL792-3 NORMATIVE 5
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL5031-1 NORMATIVE 5
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL5031-1 NORMATIVE 5
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL5031-1 NORMATIVE 5
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263731-4  Number of pressure injuries - stage 1 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21265-1 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Qual
  Cnt Ordinal Qualitative
  Count Point in time Random
  i Pressure ulcer Screen
  No Pressure Ulcers Survey
  Num QL  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1322     D 
   CMS OASIS   M1322     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 4:34:21 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 1 Ord [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 1: Num: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 39956
  Status (Raw): ACTIVE


57231-3   Stage of most problematic pressure injury [CMS Assessment]Stage of most problematic pressure injury [CMS Assessment]Stage of most problematic pressure injury: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Stage of most problematic pressure injury  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Status of most problematic unhealed (observable) pressure ulcer:
  Long Common Name:  Stage of most problematic pressure injury [CMS Assessment]

OBSERVATION ID IN FORM
M1324

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL793-1)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Stage I       1       LA3664-5  
  2       Stage II       2       LA3661-1  
  3       Stage III       3       LA3657-9  
  4       Stage IV       4       LA3651-2  
  5       No observable pressure ulcer or unhealed pressure ulcer       NA       LA12211-1  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL4511-3 NORMATIVE 5
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL4511-3 NORMATIVE 5
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL4511-3 NORMATIVE 5
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4511-3 NORMATIVE 5
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL5032-9 NORMATIVE 5
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL5032-9 NORMATIVE 5
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL5032-9 NORMATIVE 5
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL5032-9 NORMATIVE 5
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263724-9  Stage of most problematic pressure injury 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment