88371-0  Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]Outcome and assessment information set (OASIS) form - version D - Discharged from agency: -: Pt: ^Patient: -: CMS Assessment  

PANEL HIERARCHY  (view this panel in the LForms viewer)

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  88371-0   Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]Outcome and assessment information set (OASIS) form - version D - Discharged from agency: -: Pt: ^Patient: -: CMS Assessment    
       86257-3   CLINICAL RECORD ITEMS    
            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    
       86256-5   PATIENT HISTORY AND DIAGNOSES    
            85915-7   InfluenzaVaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?    
            57208-1   Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu season    
            85916-5   Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example, pneumovax)?    
            45956-0   Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example, pneumovax), state reason    
       88507-9   SENSORY STATUS    
            57220-6   Frequency of Pain Interfering with patient's activity or movement    
       88464-3   INTEGUMENTARY STATUS    
            85918-1   Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable?    
            57222-2   The Oldest Stage 2 pressure ulcer that is present at discharge    
            58052-2   Record date pressure ulcer first identified   {mm/dd/yyyy} 
            88508-7   Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage    
                 55124-2   Number of Stage 2 pressure ulcers   {#} 
                 54886-7   Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC   {#} 
                 55125-9   Number of Stage 3 pressure ulcers   {#} 
                 54887-5   Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC   {#} 
                 55126-7   Number of Stage 4 pressure ulcers   {#} 
                 54890-9   Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC   {#} 
                 54893-3   Number of unstageable pressure ulcers/injuries due to non-removable dressing/device   {#} 
                 54894-1   Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC   {#} 
                 54946-9   Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar   {#} 
                 54947-7   Number of these unstageable pressure ulcers that were present at most recent SOC/ROC   {#} 
                 54950-1   Number of unstageable pressure injuries presenting as deep tissue injury   {#} 
                 54951-9   Number of these unstageable pressure ulcers that were present at most recent SOC/ROC   {#} 
            57231-3   Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable    
            57232-1   Does this patient have a Stasis Ulcer?    
            57233-9   Current Number of Stasis Ulcer(s) that are Observable   {#} 
            57234-7   Status of Most Problematic Stasis Ulcer that is Observable    
            57235-4   Does this patient have a Surgical Wound?    
            57236-2   Status of Most Problematic Surgical Wound that is Observable    
       86249-0   RESPIRATORY STATUS    
            57237-0   When is the patient dyspneic or noticeably Short of Breath?    
       88497-3   ELIMINATION STATUS    
            46552-6   Has this patient been treated for a Urinary Tract Infection in the past 14 days?    
            46587-2   Bowel Incontinence Frequency    
       69332-5   NEURO/EMOTIONAL/BEHAVIORAL STATUS    
            46589-8   Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.    
            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): 1..6   
            46592-2   Frequency of Disruptive Behavior Symptoms (Reported or Observed): Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.    
       88500-4   ADL/IADLs    
            46595-5   Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).    
            46597-1   Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps.    
            46599-7   Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.    
            57243-8   Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).    
            57244-6   Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.    
            57245-3   Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.    
            57246-1   Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.    
            57247-9   Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.    
            57248-7   Feeding or Eating: Current ability to feed self meals and snacks safely.    
       88520-2   MEDICATIONS    
            57256-0   Medication Intervention    
            57195-0   Patient/Caregiver Drug Education Intervention    
            57285-9   Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.    
       88467-6   CARE MANAGEMENT    
            88468-4   Types and Sources of Assistance    
                 57260-2   ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding)    
                 57262-8   Medication administration (for example, oral, inhaled or injectable)    
                 57263-6   Medical procedures/treatments (for example, changing wound dressing, home exercise program)    
                 57265-1   Supervision and safety (for example, due to cognitive impairment)    
       57052-3   EMERGENT CARE    
            57276-8   Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?    
            57277-6   Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? 1..3   
       88506-1   DATA ITEMS COLLECTED AT INPATIENT FACILITY ADMISSION OR AGENCY ONLY    
            57198-4   Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan or care AND implemented?    
                 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   Intervention(s) to prevent pressure ulcers    
                 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 disposition: Where is the patient after discharge from your agency?    
            46582-3   Discharge/Transfer/Death Date   {mm/dd/yyyy} 
       89391-7   Functional Abilities and Goals - Discharge    
            89475-8   Self-Care - Discharge Performance    
                 89410-5   Eating    
                 89405-5   Oral hygiene    
                 57245-3   Toileting hygiene    
                 89397-4   Shower/bathe self    
                 89388-3   Upper body dressing    
                 89407-1   Lower body dressing    
                 89401-4   Putting on/taking off footwear    
            89474-1   Mobility - Discharge Performance    
                 89399-0   Roll left and right    
                 89395-8   Sit to lying    
                 85926-4   Lying to sitting on side of bed    
                 89393-3   Sit to stand    
                 89415-4   Chair/bed-to-chair transfer    
                 57244-6   Toilet transfer    
                 89413-9   Car transfer    
                 89386-7   Walk 10 feet    
                 89382-6   Walk 50 feet with two turns    
                 89384-2   Walk 150 feet    
                 89380-0   Walking 10 feet on uneven surfaces    
                 89421-2   1 step (curb)    
                 89417-0   4 steps    
                 89419-6   12 steps    
                 89403-0   Picking up object    
                 89411-3   Does the patient use a wheelchair and/or scooter?    
                 89376-8   Wheel 50 feet with two turns    
                 89408-9   Indicate the type of wheelchair or scooter used    
                 89378-4   Wheel 150 feet    
                 89408-9   Indicate the type of wheelchair or scooter used    
       83279-0   Health Conditions    
            83280-8   Any falls since SOC/ROC. Has the patient had any falls since SOC/ROC, whichever is more recent? Has the patient had any falls since SOC/ROC, whichever is more recent?    
            54854-5   Number of Falls Since SOC/ROC, whichever is more recent    
                 54855-2   No injury    
                 54856-0   Injury (except major)    
                 54857-8   Major injury    
 

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Outcome and assessment information set (OASIS) form - version D - Discharged from agency  Pt  ^Patient  CMS Assessment
  Long Common Name:  Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  This panel should be used for CMS OASIS-D Discharged from agency assessments performed between January 1, 2019 and December 31, 2020.
 
 

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Panel
  First Released in Version: 2.64
  Last Updated in Version: 2.66
  Order vs. Obs.: Order
  Status: Active

PARTS

Part Type    Part No.  Part Name   
Component   LP265789-0  Outcome and assessment information set (OASIS) form - version D - Discharged from agency 
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   LP260886-9  D- 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Panel Rh
  Dextro PANEL.SURVEY.CMS Rhesus
  Form version Panl Survey
  LTPAC Pnl  
  Outcome and assessment information set Point in time  
  Pan Random  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:20 PM
  Long Common Name: Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  Fully Specified Name: Outcome and assessment information set (OASIS) form - version D - Discharged from agency: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 12
  ID: 94941
  # of Panel Elements: 116
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



86257-3   Clinical Record Items - transfer or discharge [CMS Assessment]Clinical Record Items - transfer or discharge [CMS Assessment]Clinical record items - transfer or discharge: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Clinical record items - transfer or discharge  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  CLINICAL RECORD ITEMS
  Long Common Name:  Clinical Record Items - transfer or discharge [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  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]
  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]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250643-6  Clinical record items - transfer or discharge 
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 
Fragments for synonyms   LP100598-4  Discharge 

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

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:20 PM
  Long Common Name: Clinical Record Items - transfer or discharge [CMS Assessment]
  Fully Specified Name: Clinical record items - transfer or discharge: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 6
  ID: 91798
  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 12:53:20 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 12:53:20 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 9, go to M1041.

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 12:53:20 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


86256-5   Patient history and diagnoses - transfer or discharge from agency [CMS Assessment]Patient history and diagnoses - transfer or discharge from agency [CMS Assessment]Patient history and diagnoses - transfer or discharge from agency: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Patient history and diagnoses - transfer or discharge from agency  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  PATIENT HISTORY AND DIAGNOSES
  Long Common Name:  Patient history and diagnoses - transfer or discharge from agency [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [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]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250644-4  Patient history and diagnoses - transfer or discharge from agency 
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 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP91302-7  History 

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

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:20 PM
  Long Common Name: Patient history and diagnoses - transfer or discharge from agency [CMS Assessment]
  Fully Specified Name: Patient history and diagnoses - transfer or discharge from agency: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 9
  ID: 91797
  Status (Raw): ACTIVE


85915-7   Episode of care includes influenza vaccination season [CMS Assessment]Episode of care includes influenza vaccination season [CMS Assessment]Episode of care includes influenza vaccination season: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Episode of care includes influenza vaccination season  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  InfluenzaVaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?
  Long Common Name:  Episode of care includes influenza vaccination season [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Episode of care (defined as SOC/ROC to Transfer/Discharge) includes any dates on or between October 1 and March 31
 
 

OBSERVATION ID IN FORM
M1041

SKIP LOGIC
If 0, go to M1051

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

NORMATIVE ANSWER LIST    (LL4256-5)  
 
Source: National Institutes of Health Toolbox
  SEQ#        Answer        Score        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  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [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]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249825-3  Episode of care includes influenza vaccination season 
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 Screen
  EOC QL Survey
  Finding Qual  
  Findings Qualitative  
  Ordinal Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1041     D 
   CMS OASIS   M1041     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:20 PM
  Long Common Name: Episode of care includes influenza vaccination season [CMS Assessment]
  Fully Specified Name: Episode of care includes influenza vaccination season: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 7
  ID: 91454
  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
  Override Display Name for Form:  Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu season
  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
M1046

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    (LL4495-9)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)       1       LA27623-0  
  2       Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)       2       LA27624-8  
  3       Yes; received from another health care provider (for example, physician, pharmacist)       3       LA27625-5  
  4       No; patient offered and declined       4       LA27626-3  
  5       No; patient assessed and determined to have medical contraindication(s)       5       LA27627-1  
  6       No; not indicated - patient does not meet age/condition guidelines for influenza vaccine       6       LA27628-9  
  7       No; inability to obtain vaccine due to declared shortage       7       LA27629-7  
  8       No; patient did not receive the vaccine due to reasons other than those listed in responses 4-7.       8       LA27630-5  

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
  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 12:53:20 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


85916-5   Pneumococcal vaccination received [CMS Assessment]Pneumococcal vaccination received [CMS Assessment]Pneumococcal vaccination received: Find: Lifetime: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Pneumococcal vaccination received  Find  Lifetime  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example, pneumovax)?
  Long Common Name:  Pneumococcal vaccination received [CMS Assessment]

OBSERVATION ID IN FORM
M1051

SKIP LOGIC
If Yes, Go to M2005 at TRN; Go to M1242 at DC

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

NORMATIVE ANSWER LIST    (LL4256-5)  
 
Source: National Institutes of Health Toolbox
  SEQ#        Answer        Score        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  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [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]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249826-1  Pneumococcal vaccination received 
Property   LP6813-2  Find   [Finding] 
Time   LP203024-7  Lifetime 
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 Ordinal Qualitative
  Finding Ql Screen
  Findings Qual Survey

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1051     D 
   CMS OASIS   M1051     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:20 PM
  Long Common Name: Pneumococcal vaccination received [CMS Assessment]
  Fully Specified Name: Pneumococcal vaccination received: Find: Lifetime: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 3
  ID: 91455
  Status (Raw): ACTIVE


45956-0   Reason pneumococcal vaccine not received [CMS Assessment]Reason pneumococcal vaccine not received [CMS Assessment]Reason pneumococcal vaccine not received: Find: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Reason pneumococcal vaccine not received  Find  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example, pneumovax), state reason
  Long Common Name:  Reason pneumococcal vaccine not received [CMS Assessment]

OBSERVATION ID IN FORM
M1056

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.17
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from MDS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL4497-5)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Offered and declined       1       LA186-9  
  2       Assessed and determined to have medical contraindication(s)       2       LA12154-3  
  3       Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine       3       LA27632-1  
  4       None of the above       4       LA9-3  

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
  45981-8 MDS full assessment form - version 2.0 LL49-8 NORMATIVE 3
  46076-6 Minimum Data Set (MDS) supplemental items section - version 2.0 LL49-8 NORMATIVE 3
  46104-6 MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update LL49-8 NORMATIVE 3
  52743-2 Continuity Assessment Record and Evaluation (CARE) tool - Acute Care LL677-6 NORMATIVE 3
  52744-0 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission LL677-6 NORMATIVE 3
  52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge LL677-6 NORMATIVE 3
  52746-5 Continuity Assessment Record and Evaluation (CARE) tool - Interim LL677-6 NORMATIVE 3
  52748-1 Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission LL677-6 NORMATIVE 3
  54580-6 Minimum Data Set - version 3.0 LL677-6 NORMATIVE 3
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment] LL4497-5 NORMATIVE 4
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4497-5 NORMATIVE 4
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment] LL677-6 NORMATIVE 3
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment] LL677-6 NORMATIVE 3
  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] LL677-6 NORMATIVE 3
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment] LL677-6 NORMATIVE 3
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment] LL677-6 NORMATIVE 3
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment] LL677-6 NORMATIVE 3
  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] LL677-6 NORMATIVE 3
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment] LL4497-5 NORMATIVE 4
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4497-5 NORMATIVE 4
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment] LL677-6 NORMATIVE 3
  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] LL677-6 NORMATIVE 3
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment] LL677-6 NORMATIVE 3
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment] LL677-6 NORMATIVE 3
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment] LL677-6 NORMATIVE 3
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment] LL677-6 NORMATIVE 3
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment] LL677-6 NORMATIVE 3
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment] LL677-6 NORMATIVE 3
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment] LL677-6 NORMATIVE 3
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment] LL677-6 NORMATIVE 3
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75498-3  Reason pneumococcal 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   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 MDS   O0300B     1.16.1 
   CMS MDS   O0300B     1.15.1 
   CMS MDS   O0300B     1.14.1 
   CMS MDS   O0300B     1.17.1 
   CMS OASIS   M1056     D 
   CMS OASIS   M1056     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:20 PM
  Attachment Units Required: N
  Long Common Name: Reason pneumococcal vaccine not received [CMS Assessment]
  Fully Specified Name: Reason pneumococcal vaccine not received: Find: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 5
  ID: 39352
  Status (Raw): ACTIVE


88507-9   OASIS D - Sensory status - discharge from agency [CMS Assessment]OASIS D - Sensory status - discharge from agency [CMS Assessment]OASIS D - Sensory status - discharge from agency: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
OASIS D - Sensory status - discharge from agency  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  SENSORY STATUS
  Long Common Name:  OASIS D - Sensory status - discharge from agency [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.64
  Last Updated in Version: 2.64
  Order vs. Obs.: Subset
  Status: Active

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

PARTS

Part Type    Part No.  Part Name   
Component   LP266146-2  OASIS D - Sensory status - discharge from agency 
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   LP100598-4  Discharge 
Fragments for synonyms   LP260886-9  D- 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Panel Random
  Dextro PANEL.SURVEY.CMS Rh
  Disch Panl Rhesus
  Outcome and assessment information set Pnl Survey
  Pan Point in time  

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:20 PM
  Long Common Name: OASIS D - Sensory status - discharge from agency [CMS Assessment]
  Fully Specified Name: OASIS D - Sensory status - discharge from agency: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 7
  ID: 95083
  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 12:53:21 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


88464-3   OASIS D - Integumentary status - discharge from agency [CMS Assessment]OASIS D - Integumentary status - discharge from agency [CMS Assessment]OASIS D - Integumentary status - discharge from agency: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
OASIS D - Integumentary status - discharge from agency  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  INTEGUMENTARY STATUS
  Long Common Name:  OASIS D - Integumentary status - discharge from agency [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.64
  Last Updated in Version: 2.64
  Order vs. Obs.: Subset
  Status: Active

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

PARTS

Part Type    Part No.  Part Name   
Component   LP265808-8  OASIS D - Integumentary status - discharge from agency 
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 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP260886-9  D- 
Fragments for synonyms   LP57618-8  OASIS 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Panel Random
  Dextro PANEL.SURVEY.CMS Rh
  Disch Panl Rhesus
  Outcome and assessment information set Pnl Survey
  Pan Point in time  

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:21 PM
  Long Common Name: OASIS D - Integumentary status - discharge from agency [CMS Assessment]
  Fully Specified Name: OASIS D - Integumentary status - discharge from agency: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 7
  ID: 95039
  Status (Raw): ACTIVE


85918-1   Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]Unhealed pressure injury at stage 2 or higher or designated as unstageable: Find: Pt: ^Patient: Ord: CMS Assessment  

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  Ord  CMS Assessment
  Override Display Name for Form:  Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable?
  Long Common Name:  Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Excludes Stage 1 pressure inuries and all healed pressure ulcers/injuries.
 
 

OBSERVATION ID IN FORM
M1306

FORM CODING INSTRUCTIONS
Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries.

SKIP LOGIC
If 0, go to M1324.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.64
  Order vs. Obs.: Observation
  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  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  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   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   LP7751-3  Ord 
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 
Fragments for synonyms   LP57601-4  As 

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

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1306     D 
   CMS OASIS   M1306     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:21 PM
  Long Common Name: Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]
  Fully Specified Name: Unhealed pressure injury at stage 2 or higher or designated as unstageable: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 12
  ID: 91457
  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:  The Oldest Stage 2 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

FORM CODING INSTRUCTIONS
Excludes healed Stage 2 Pressure Ulcers

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    (LL4716-8)  
 
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       LA28343-4  
  3       No stage 2 pressure ulcers are present at discharge       NA       LA28342-6  

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 12:53:21 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
  Override Display Name for Form:  Record date pressure ulcer first identified
  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 12:53:21 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


88508-7   OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency [CMS Assessment]OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency [CMS Assessment]OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
  Long Common Name:  OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency [CMS Assessment]

OBSERVATION ID IN FORM
M1311

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.64
  Last Updated in Version: 2.64
  Order vs. Obs.: Subset
  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  
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP266149-6  OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency 
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   LP100598-4  Discharge 
Fragments for synonyms   LP260886-9  D- 
Fragments for synonyms   LP266931-7  Pressure injuries 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Panel Random
  Dextro PANEL.SURVEY.CMS Rh
  Disch Panl Rhesus
  No Pnl Survey
  Num Point in time  
  Outcome and assessment information set Pressure ulcer  
  Pan Pressure Ulcers  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1311     D 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:21 PM
  Long Common Name: OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency [CMS Assessment]
  Fully Specified Name: OASIS D - Current number of unhealed pressure injuries at each stage - discharge from agency: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 14
  ID: 95084
  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:  Number of Stage 2 pressure ulcers
  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
M1311A1

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.

SKIP LOGIC
If 0, Go to M1311B1, Stage 3.

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 12:53:21 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


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:  Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 2 [CMS Assessment]

OBSERVATION ID IN FORM
M1311A2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

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 12:53:21 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


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:  Number of Stage 3 pressure ulcers
  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
M1311B1

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, Go to M1311C1, 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 12:53:21 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


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:  Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 3 [CMS Assessment]

OBSERVATION ID IN FORM
M1311B2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

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 12:53:21 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


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:  Number of Stage 4 pressure ulcers
  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
M1311C1

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.

SKIP LOGIC
If 0, Go to M1311D1, Unstageable: Non-removable dressing/device

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 12:53:21 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


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:  Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 4 [CMS Assessment]

OBSERVATION ID IN FORM
M1311C2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

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 12:53:22 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


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:  Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
  Long Common Name:  Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]

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
M1311D1

FORM CONTEXT
Unstageable: Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.

SKIP LOGIC
If 0, Go to M1311E1, Unstageable: Slough and/or eschar

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 12:53:22 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


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:  Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing [CMS Assessment]

OBSERVATION ID IN FORM
M1311D2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

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 12:53:22 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


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:  Number of unstageable pressure ulcers/injuries 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]

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
M1311E1

FORM CONTEXT
Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

SKIP LOGIC
If 0, Go to M1311F1, Unstageable: Deep tissue injury

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 12:53:22 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


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:  Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
  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
M1311E2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

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 12:53:22 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


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:  Number of unstageable pressure injuries presenting as deep tissue injury
  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
M1311F1

FORM CONTEXT
Unstageable: Deep tissue injury

SKIP LOGIC
If 0, Go to M1324

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 12:53:22 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


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:  Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
  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
M1311F2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

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 12:53:22 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


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:  Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable
  Long Common Name:  Stage of most problematic pressure injury [CMS Assessment]

OBSERVATION ID IN FORM
M1324

FORM CODING INSTRUCTIONS
Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury.

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    (LL5032-9)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Stage 1       1       LA6383-9  
  2       Stage 2       2       LA6384-7  
  3       Stage 3       3       LA6385-4  
  4       Stage 4       4       LA6386-2  
  5       Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries               LA29202-1  

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 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   M1324     D 
   CMS OASIS   M1324     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:22 PM
  Attachment Units Required: N
  Long Common Name: Stage of most problematic pressure injury [CMS Assessment]
  Fully Specified Name: Stage of most problematic pressure injury: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51864
  Status (Raw): ACTIVE


57232-1   Stasis ulcer [CMS Assessment]Stasis ulcer [CMS Assessment]Stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Stasis ulcer  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Does this patient have a Stasis Ulcer?
  Long Common Name:  Stasis ulcer [CMS Assessment]

OBSERVATION ID IN FORM
M1330

SKIP LOGIC
If 0, go to M1340. If 3, go to M1340.

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    (LL4512-1)  
 
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, patient has BOTH observable and unobservable stasis ulcers       1       LA12402-6  
  3       Yes, patient has observable stasis ulcers ONLY       2       LA12400-0  
  4       Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device)       3       LA12401-8  

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 LL794-9 NORMATIVE 3
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL794-9 NORMATIVE 3
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL794-9 NORMATIVE 3
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up LL794-9 NORMATIVE 3
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL794-9 NORMATIVE 3
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL4512-1 NORMATIVE 4
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL4512-1 NORMATIVE 4
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL4512-1 NORMATIVE 4
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4512-1 NORMATIVE 4
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL4512-1 NORMATIVE 4
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL4512-1 NORMATIVE 4
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4512-1 NORMATIVE 4
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL4512-1 NORMATIVE 4
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75668-1  Stasis ulcer 
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   LP267480-4  Ulcer 

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

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1330     D 
   CMS OASIS   M1330     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:22 PM
  Attachment Units Required: N
  Long Common Name: Stasis ulcer [CMS Assessment]
  Fully Specified Name: Stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 2
  ID: 51866
  Status (Raw): ACTIVE


57233-9   Number of stasis ulcers [CMS Assessment]Number of stasis ulcers [CMS Assessment]Number of stasis ulcers: Num: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of stasis ulcers  Num  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Current Number of Stasis Ulcer(s) that are Observable
  Long Common Name:  Number of stasis ulcers [CMS Assessment]

OBSERVATION ID IN FORM
M1332

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; Changed SCALE from Qn to Ord because this term has an answer list.

NORMATIVE ANSWER LIST    (LL795-6)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       One       1       LA6306-0  
  2       Two       2       LA6404-3  
  3       Three       3       LA6395-3  
  4       Four or more       4       LA6200-5  

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]
  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   LP75245-8  Number of stasis ulcers 
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] 

RELATED NAMES
  # stasis ulcers Number Random
  Centers for Medicare and Medicaid Assessment Ordinal Screen
  Cnt Point in time Survey
  Count QL  
  No Qual  
  Num Qualitative  

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   M1332     D 
   CMS OASIS   M1332     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:22 PM
  Attachment Units Required: N
  Long Common Name: Number of stasis ulcers [CMS Assessment]
  Fully Specified Name: Number of stasis ulcers: Num: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 4
  ID: 51867
  Status (Raw): ACTIVE


57234-7   Status of most problematic stasis ulcer [CMS Assessment]Status of most problematic stasis ulcer [CMS Assessment]Status of most problematic stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Status of most problematic stasis ulcer  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Status of Most Problematic Stasis Ulcer that is Observable
  Long Common Name:  Status of most problematic stasis ulcer [CMS Assessment]

OBSERVATION ID IN FORM
M1334

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    (LL4513-9)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Fully granulating       1       LA6203-9  
  2       Early/partial granulation       2       LA6193-2  
  3       Not healing       3       LA6300-3  

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 LL796-4 NORMATIVE 4
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL796-4 NORMATIVE 4
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL796-4 NORMATIVE 4
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up LL796-4 NORMATIVE 4
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL796-4 NORMATIVE 4
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL4513-9 NORMATIVE 3
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL4513-9 NORMATIVE 3
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL4513-9 NORMATIVE 3
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4513-9 NORMATIVE 3
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL4513-9 NORMATIVE 3
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL4513-9 NORMATIVE 3
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4513-9 NORMATIVE 3
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL4513-9 NORMATIVE 3
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75676-4  Status of most problematic stasis ulcer 
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   LP267480-4  Ulcer 

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

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1334     D 
   CMS OASIS   M1334     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:22 PM
  Attachment Units Required: N
  Long Common Name: Status of most problematic stasis ulcer [CMS Assessment]
  Fully Specified Name: Status of most problematic stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51868
  Status (Raw): ACTIVE


57235-4   Surgical wound [CMS Assessment]Surgical wound [CMS Assessment]Surgical wound: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical wound  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Does this patient have a Surgical Wound?
  Long Common Name:  Surgical wound [CMS Assessment]

OBSERVATION ID IN FORM
M1340

SKIP LOGIC
If 0, go to M1400. If 2, go to M1400.

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.

NORMATIVE ANSWER LIST    (LL849-1)  
 
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, patient has at least one observable surgical wound       1       LA12633-6  
  3       Surgical wound known but not observable due to non-removable dressing/device       2       LA12634-4  

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   LP75696-2  Surgical wound 
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   LP100628-9  Surgical 

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

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1340     D 
   CMS OASIS   M1340     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Attachment Units Required: N
  Long Common Name: Surgical wound [CMS Assessment]
  Fully Specified Name: Surgical wound: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 2
  ID: 51869
  Status (Raw): ACTIVE


57236-2   Status of most problematic surgical wound [CMS Assessment]Status of most problematic surgical wound [CMS Assessment]Status of most problematic surgical wound: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Status of most problematic surgical wound  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Status of Most Problematic Surgical Wound that is Observable
  Long Common Name:  Status of most problematic surgical wound [CMS Assessment]

OBSERVATION ID IN FORM
M1342

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    (LL796-4)  
 
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  

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   LP75677-2  Status of most problematic surgical wound 
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   LP100628-9  Surgical 

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

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1342     D 
   CMS OASIS   M1342     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Attachment Units Required: N
  Long Common Name: Status of most problematic surgical wound [CMS Assessment]
  Fully Specified Name: Status of most problematic surgical wound: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51870
  Status (Raw): ACTIVE


86249-0   OASIS C2, D - Respiratory status - follow-up or discharge [CMS Assessment]OASIS C2, D - Respiratory status - follow-up or discharge [CMS Assessment]OASIS C2, D - Respiratory status - follow-up or discharge: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
OASIS C2, D - Respiratory status - follow-up or discharge  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  RESPIRATORY STATUS
  Long Common Name:  OASIS C2, D - Respiratory status - follow-up or discharge [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.64
  Order vs. Obs.: Subset
  Status: Active.
Change Reason: Added "D" to Component to indicate the use of this term OASIS D.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  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]
  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]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250639-4  OASIS C2, D - Respiratory status - follow-up or discharge 
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   LP100598-4  Discharge 
Fragments for synonyms   LP260886-9  D- 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Rh
  Dextro Panl Rhesus
  Disch Pnl Survey
  Outcome and assessment information set Point in time  
  Pan Random  
  Panel Resp status  

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Long Common Name: OASIS C2, D - Respiratory status - follow-up or discharge [CMS Assessment]
  Fully Specified Name: OASIS C2, D - Respiratory status - follow-up or discharge: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 9
  ID: 91790
  Status (Raw): ACTIVE


57237-0   Exertion level causing shortness of breath [CMS Assessment]Exertion level causing shortness of breath [CMS Assessment]Exertion level causing shortness of breath: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Exertion level causing shortness of breath  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  When is the patient dyspneic or noticeably Short of Breath?
  Long Common Name:  Exertion level causing shortness of breath [CMS Assessment]

OBSERVATION ID IN FORM
M1400

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; Change Component to reflect that this term is not about the time ("when") shortness of breath occurs.

NORMATIVE ANSWER LIST    (LL797-2)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Patient is not short of breath       0       LA12224-4  
  2       When walking more than 20 feet, climbing stairs       1       LA6443-1  
  3       With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet)       2       LA6446-4  
  4       With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation       3       LA6445-6  
  5       At rest (during day or night)       4       LA6158-5  

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]
  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   LP253616-9  Exertion level causing shortness of breath 
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   LP20732-1  Level 

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

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1400     D 
   CMS OASIS   M1400     C2 

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Attachment Units Required: N
  Long Common Name: Exertion level causing shortness of breath [CMS Assessment]
  Fully Specified Name: Exertion level causing shortness of breath: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51871
  Status (Raw): ACTIVE


88497-3   OASIS D - Elimination status - discharge from agency [CMS Assessment]OASIS D - Elimination status - discharge from agency [CMS Assessment]OASIS D - Elimination status - discharge from agency: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
OASIS D - Elimination status - discharge from agency  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  ELIMINATION STATUS
  Long Common Name:  OASIS D - Elimination status - discharge from agency [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.64
  Last Updated in Version: 2.64
  Order vs. Obs.: Subset
  Status: Active

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

PARTS

Part Type    Part No.  Part Name   
Component   LP266135-5  OASIS D - Elimination status - discharge from agency 
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   LP100598-4  Discharge 
Fragments for synonyms   LP260886-9  D- 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Panel Random
  Dextro PANEL.SURVEY.CMS Rh
  Disch Panl Rhesus
  Outcome and assessment information set Pnl Survey
  Pan Point in time  

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Long Common Name: OASIS D - Elimination status - discharge from agency [CMS Assessment]
  Fully Specified Name: OASIS D - Elimination status - discharge from agency: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 7
  ID: 95073
  Status (Raw): ACTIVE


46552-6   Treated for urinary tract infection in past 14 days [CMS Assessment]Treated for urinary tract infection in past 14 days [CMS Assessment]Treated for urinary tract infection in past 14D: Find: 14D: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Treated for urinary tract infection in past 14D  Find  14D  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Has this patient been treated for a Urinary Tract Infection in the past 14 days?
  Long Common Name:  Treated for urinary tract infection in past 14 days [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Identifies treatment of urinary tract infection during the past 14 days.
 
 

OBSERVATION ID IN FORM
M1600

TYPE OF ENTRY
Question

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; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms.

NORMATIVE ANSWER LIST    (LL4528-7)  
 
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       Patient on prophylactic treatment       NA       LA6337-5  

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 LL276-7 NORMATIVE 4
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL276-7 NORMATIVE 4
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL276-7 NORMATIVE 4
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4528-7 NORMATIVE 3
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL276-7 NORMATIVE 4
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4528-7 NORMATIVE 3
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL276-7 NORMATIVE 4
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75787-9  Treated for urinary tract infection in past 14D   [Treated for urinary tract infection in past 14 days] 
Property   LP6813-2  Find   [Finding] 
Time   LP203020-5  14D   [14 days] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP200100-8  Past 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Ordinal Screen
  Finding Ql Survey
  Findings Qual  
  Last Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1600     D 
   CMS OASIS   M1600     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Attachment Units Required: N
  Long Common Name: Treated for urinary tract infection in past 14 days [CMS Assessment]
  Fully Specified Name: Treated for urinary tract infection in past 14D: Find: 14D: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 8
  ID: 39974
  Status (Raw): ACTIVE


46587-2   Bowel incontinence frequency [CMS Assessment]Bowel incontinence frequency [CMS Assessment]Bowel incontinence frequency: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Bowel incontinence frequency  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Bowel Incontinence Frequency
  Long Common Name:  Bowel incontinence frequency [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Identifies how often the patient experiences bowel incontinence.
 
 

OBSERVATION ID IN FORM
M1620

TYPE OF ENTRY
Question

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 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    (LL4529-5)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Very rarely or never has bowel incontinence       0       LA6440-7  
  2       Less than once weekly       1       LA6252-6  
  3       One to three times weekly       2       LA6307-8  
  4       Four to six times weekly       3       LA6201-3  
  5       On a daily basis       4       LA6302-9  
  6       More often than once daily       5       LA6263-3  
  7       Patient has ostomy for bowel elimination       NA       LA6330-0  

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 LL279-1 NORMATIVE 8
  57039-0 Outcome and assessment information set (OASIS) form - version C LL279-1 NORMATIVE 8
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL279-1 NORMATIVE 8
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL279-1 NORMATIVE 8
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up LL279-1 NORMATIVE 8
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL279-1 NORMATIVE 8
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL279-1 NORMATIVE 8
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL279-1 NORMATIVE 8
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL4529-5 NORMATIVE 7
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4529-5 NORMATIVE 7
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL279-1 NORMATIVE 8
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL4529-5 NORMATIVE 7
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4529-5 NORMATIVE 7
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL279-1 NORMATIVE 8
  

PARTS

Part Type    Part No.  Part Name   
Component   LP74573-4  Bowel incontinence frequency 
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   M1620     D 
   CMS OASIS   M1620     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Attachment Units Required: N
  Long Common Name: Bowel incontinence frequency [CMS Assessment]
  Fully Specified Name: Bowel incontinence frequency: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 3
  ID: 40013
  Status (Raw): ACTIVE


69332-5   Neuro and emotional and behavioral status - discharge from agency [CMS Assessment]Neuro and emotional and behavioral status - discharge from agency [CMS Assessment]Neuro & emotional & behavioral status - discharge from agency: -: -: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Neuro & emotional & behavioral status - discharge from agency  ^Patient  CMS Assessment
  Override Display Name for Form:  NEURO/EMOTIONAL/BEHAVIORAL STATUS
  Long Common Name:  Neuro and emotional and behavioral status - discharge from agency [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.38
  Last Updated in Version: 2.61
  Order vs. Obs.: Subset
  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 TIMING to "-" because panel children have different TIMINGs.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  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   LP135994-4  Neuro & emotional & behavioral status - discharge from agency   [Neuro and emotional and behavioral status - discharge from agency] 
Time   LP70420-2 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Pan Pnl
  Disch Panel Survey
  Neuro & emot & behav status - d/c from agency PANEL.SURVEY.CMS  
  Neuro emotional behavioral status Panl  

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Attachment Units Required: N
  Long Common Name: Neuro and emotional and behavioral status - discharge from agency [CMS Assessment]
  Fully Specified Name: Neuro & emotional & behavioral status - discharge from agency: -: -: ^Patient: -: CMS Assessment
     
  Component Word Count: 7
  ID: 68643
  Status (Raw): ACTIVE


46589-8   Cognitive functioning [CMS Assessment]Cognitive functioning [CMS Assessment]Cognitive functioning: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Cognitive functioning  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
  Long Common Name:  Cognitive functioning [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Identifies the patient's current level of cognitive functioning, including alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
 
 

OBSERVATION ID IN FORM
M1700

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    (LL281-7)  
 
Source: 
  SEQ#        Answer        Code         Answer ID    
  1       Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.       0       LA6153-6  
  2       Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.       1       LA6362-3  
  3       Requires assistance and some direction in specific situations (for example, all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.       2       LA6359-9  
  4       Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and recall directions more than half the time.       3       LA12251-7  
  5       Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.       4       LA6399-5  

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
  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]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [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   LP74625-2  Cognitive functioning 
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   M1700     D 
   CMS OASIS   M1700     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 12:53:23 PM
  Attachment Units Required: N
  Long Common Name: Cognitive functioning [CMS Assessment]
  Fully Specified Name: Cognitive functioning: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 2
  ID: 40015
  Status (Raw): ACTIVE


58104-1   When confused within the last 14 days [CMS Assessment]When confused within the last 14 days [CMS Assessment]When confused within the last 14D: Find: 14D: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
When confused within the last 14D  Find  14D  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  When Confused (Reported or Observed Within the Last 14 Days)
  Long Common Name:  When confused within the last 14 days [CMS Assessment]

OBSERVATION ID IN FORM
M1710

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;Removed "reported or observed" from the COMPONENT because an oberservation of this nature must either be reported or observed, and therefore stating so is redundant;Changed "days" to "D" to match LOINC conventions for abbreviating time.

NORMATIVE ANSWER LIST    (LL282-5)  
 
Source: 
  SEQ#        Answer        Code         Answer ID    
  1       Never       0       LA6270-8  
  2       In new or complex situations only       1       LA6231-0  
  3       On awakening or at night only       2       LA6303-7  
  4       During the day and evening, but not constantly       3       LA6190-8  
  5       Constantly       4       LA6174-2  
  6       Patient nonresponsive       NA       LA6335-9  

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]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [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   LP98187-5  When confused within the last 14D   [When confused within the last 14 days] 
Property   LP6813-2  Find   [Finding] 
Time   LP203020-5  14D   [14 days] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP200101-6  Last 

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

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1710     D 
   CMS OASIS   M1710     C2