88371-0
Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
Active
Term Description
This panel should be used for CMS OASIS-D Discharged from agency assessments performed between January 1, 2019 and December 31, 2019 and CMS OASIS-D1 Discharged from agency assessments performed after January 1, 2020.
Source: Regenstrief LOINC
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 88371-0 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment] | |||
| Indent86257-3 | CLINICAL RECORD ITEMS | |||
| Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent86256-5 | PATIENT HISTORY AND DIAGNOSES | |||
| Indent Indent85915-7 | 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? | |||
| Indent Indent57208-1 | Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season | |||
| Indent Indent72057-3 | Pneumococcal vaccination been received | |||
| Indent Indent45956-0 | Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example, pneumovax), state reason | |||
| Indent88507-9 | SENSORY STATUS | |||
| Indent Indent57220-6 | Frequency of Pain Interfering with patient's activity or movement | |||
| Indent88464-3 | INTEGUMENTARY STATUS | |||
| Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? | |||
| Indent Indent57222-2 | The Oldest Stage 2 pressure ulcer that is present at discharge | |||
| Indent Indent58052-2 | Record date pressure ulcer first identified | {mm/dd/yyyy} | ||
| Indent Indent88508-7 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent54946-9 | Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent54951-9 | Number of these unstageable pressure ulcers that were present at most recent SOC/ROC | {#} | ||
| Indent Indent57231-3 | Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable | |||
| Indent Indent57232-1 | Does this patient have a Stasis Ulcer? | |||
| Indent Indent57233-9 | Current Number of Stasis Ulcer(s) that are Observable | {#} | ||
| Indent Indent57234-7 | Status of Most Problematic Stasis Ulcer that is Observable | |||
| Indent Indent57235-4 | Does this patient have a Surgical Wound? | |||
| Indent Indent57236-2 | Status of Most Problematic Surgical Wound that is Observable | |||
| Indent86249-0 | RESPIRATORY STATUS | |||
| Indent Indent57237-0 | When is the patient dyspneic or noticeably Short of Breath? | |||
| Indent88497-3 | ELIMINATION STATUS | |||
| Indent Indent46552-6 | Has this patient been treated for a Urinary Tract Infection in the past 14 days? | |||
| Indent Indent46587-2 | Bowel Incontinence Frequency | |||
| Indent69332-5 | NEURO/EMOTIONAL/BEHAVIORAL STATUS | |||
| Indent Indent46589-8 | Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands. | |||
| Indent Indent58104-1 | When Confused (Reported or Observed Within the Last 14 Days) | |||
| Indent Indent86495-9 | When Anxious (Reported or Observed Within the Last 14 Days) | |||
| Indent Indent46473-5 | Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed): | 1..6 | ||
| Indent Indent46592-2 | 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. | |||
| Indent88500-4 | ADL/IADLs | |||
| Indent Indent46595-5 | 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). | |||
| Indent Indent46597-1 | 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. | |||
| Indent Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
| Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
| Indent Indent57244-6 | Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. | |||
| Indent Indent57245-3 | 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. | |||
| Indent Indent57246-1 | Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. | |||
| Indent Indent57247-9 | 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. | |||
| Indent Indent57248-7 | Feeding or Eating: Current ability to feed self meals and snacks safely. | |||
| Indent88520-2 | MEDICATIONS | |||
| Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent57195-0 | Patient/Caregiver Drug Education Intervention | |||
| Indent Indent57285-9 | 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. | |||
| Indent88467-6 | CARE MANAGEMENT | |||
| Indent Indent88468-4 | Types and Sources of Assistance | |||
| Indent Indent Indent57260-2 | ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding) | |||
| Indent Indent Indent57262-8 | Medication administration (for example, oral, inhaled or injectable) | |||
| Indent Indent Indent57263-6 | Medical procedures/treatments (for example, changing wound dressing, home exercise program) | |||
| Indent Indent Indent57265-1 | Supervision and safety (for example, due to cognitive impairment) | |||
| Indent57052-3 | EMERGENT CARE | |||
| Indent Indent57276-8 | 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)? | |||
| Indent Indent57277-6 | Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? | 1..3 | ||
| Indent88506-1 | DATA ITEMS COLLECTED AT INPATIENT FACILITY ADMISSION OR AGENCY ONLY | |||
| Indent Indent57198-4 | 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? | |||
| Indent Indent Indent57270-1 | Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care | |||
| Indent Indent Indent57271-9 | Falls prevention interventions | |||
| Indent Indent Indent57272-7 | Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment | |||
| Indent Indent Indent57273-5 | Intervention(s) to monitor and mitigate pain | |||
| Indent Indent Indent57274-3 | Intervention(s) to prevent pressure ulcers | |||
| Indent Indent Indent57275-0 | Pressure ulcer treatment based on principles of moist wound healing | |||
| Indent Indent46578-1 | To which Inpatient Facility has the patient been admitted? | |||
| Indent Indent55128-3 | Discharge disposition: Where is the patient after discharge from your agency? | |||
| Indent Indent46582-3 | Discharge/Transfer/Death Date | {mm/dd/yyyy} | ||
| Indent89391-7 | Functional Abilities and Goals - Discharge | |||
| Indent Indent89475-8 | Self-Care - Discharge Performance | |||
| Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent89474-1 | Mobility - Discharge Performance | |||
| Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent95738-1 | Does the patient use a wheelchair and/or scooter? | |||
| Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent83279-0 | Health Conditions | |||
| Indent Indent83280-8 | 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? | |||
| Indent Indent54854-5 | Number of Falls Since SOC/ROC, whichever is more recent | |||
| Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent54857-8 | Major injury |
Fully-Specified Name
- Component
- Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.64
- Last Updated
- Version 2.77
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Release 2.67: COMPONENT: Assessment version updated to reflect must recent version
- Order vs. Observation
- Order
- Panel Type
- Panel
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=88371-0 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/88371-0
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