Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. HIT Standards and Patient Assessment Summary Documents

12/01/2011

The final step in the Patient Assessment Summary project was the application of HIT standards in support of the interoperable exchange of Assessment Summary content across providers. “Toolkits” for the MDS3.0 and OASIS-C Patient Assessment Summary documents were compiled to assist in the transition to conveyance of Assessment Summary content using:

  • Logical Object Identifiers Names and Codes (LOINC) and SNOMED CT as the primary terminologies of choice (other vocabularies were used as appropriate).

  • HL7 Continuity of Care Document (CCD)/HITSP C32 standards for patient summaries as identified in the July 28, 2010 ONC Final Rule: HIT -- Initial Set of Standards, Implementation Specifications, and Certification Criteria for EHR Technology.

Building on the MDS3.0 and OASIS-C Rosetta Stones described in Appendix A, the “Toolkit: OASIS-C Extract for Health Information Exchange” and the “Toolkit: MDS3.0 Extract for Health Information Exchange” each contain mappings of the Assessment Summary data elements to:

  • Logical Object Identifiers Names and Codes (LOINC) codes expressing MDS/OASIS concepts in a one-to-one exact representation using a standardized, computable terminology.

  • SNOMED CT codes expressing MDS/OASIS concepts in a "best available" representation using a standardized, computable terminology.

  • Other vocabularies and code sets as appropriate (i.e., ICD-9-CM, ICD-10-CM, CDC Race & Ethnicity Codes, CVX).

In addition, an analysis was undertaken of the compatibility of the MDS3.0 and OASIS-C Patient Assessment Summary data elements with the ONC named standards for patient summaries (i.e., the HL7 Continuity of Care Document (CCD) standard and the HITSP C32 component specification). Compatibility, to the extent possible, with the ONC named standards is important for supporting efficient and cost-effective interoperable health information exchange across health care providers. Each MDS3.0 and OASIS-C Assessment Summary data element was matched to:

  • HITSP C32 identified C83 component modules;
  • HITSP C83 identified C154 data elements;
  • HL7 CCD header or body section.

The requirements identified for each Assessment Summary data element, and any issues or discrepancies discovered, are captured in the MDS3.0 Extract Toolkit and the OASIS-C Extract Toolkit. In general though, the issues identified in the mapping to HL7 CCD and HITSP C32 requirements fell into the following categories:

Issue Example
1. HITSP specifications require a data element that is not supported by MDS/OASIS HITSP C83 requires the data element “Encounter ID” for an “Encounter Event Entry”. Neither the MDS3.0 nor the OASIS-C has an “Encounter ID”.
2. HITSP data element specifications do not support MDS/OASIS item The format of the MDS3.0 pneumococcal vaccination data item does not lend itself to parameters of the C83 Immunization Content module data elements.
3. HITSP specifications are not completed HITSP has not defined a Content Module nor Data Elements for Functional Status items.
4. The HITSP Value set does not fully support MDS/OASIS response options The HITSP value set for "No Immunization Reason" detailed in C80 Table 2-90 does not fully support the MDS3.0 responses for this question (i.e., "Resident not in facility during this year's flu season", "Received outside of this facility", "Not offered").

Future work will be required to ensure that MDS3.0 and OASIS-C Patient Assessment Summary data can be appropriately conveyed in accordance with ONC named standards for patient summaries.

TABLE J-1: Participants in the MDS3.0 Expert Panel
Sponsoring Organization Panelists
Nursing Facility Experts
Kindred Healthcare Larry Wolf Health IT Strategist
Tami Johnson Kindred Healthcare -- Health Services Division
Vermont Healthcare Association Laura Pelosi Executive Director
Vermont Healthcare Association
Deborah Badger MDS Coordinator
Woodridge Nursing Home
Paula Ducharme Director of Nursing Services & MDS Coordinator
Derby Green Nursing Home
Kristina Laychak MDS Coordinator
The Manor Nursing Home
Melinda Sanborn Director of Nursing Services
The Pines @ Rutland Nursing Home
Integrated Delivery Networks
Citizens Memorial Healthcare Chad Cahow Citizens Memorial Healthcare
Valerie Noblitt Director of Home Care
Citizens Memorial Healthcare
University of Pittsburgh/ University of Pittsburgh Medical Center (UPMC) Steven M. Handler MD, PhD, CMD Assistant Professor; Medical Director Long-term Care Health Information Technology,
University of Pittsburgh/ UPMC
Home Health Experts
Visiting Nurse Service of New York (VNSNY) Sally Sobolewski VNSNY
Thomas Check Chief Information Officer
VNSNY
Nurse Informaticists
Alliance in Nursing (in conjunction with the AMIA Nursing Informatics Working Group) Bonnie Westra, PhD, RN, FAAN Associate Professor, Co-Director ICNP Research Center
University of Minnesota, School of Nursing
Dana Alexander GE Healthcare
Gregory L. Alexander, PhD, MHA, MIS, RN Assistant Professor
University of Missouri-Columbia, Sinclair School of Nursing
Rosemary Kennedy, MBA, RN, FAAN Associate Professor
Thomas Jefferson University, Jefferson School of Nursing
Lori L. Popejoy, PhD, APRN, GNS-BC Assistant Professor
University of Missouri-Columbia, Sinclair School of Nursing
Charlotte Weaver RN, PhD, FAAN Senior Vice President & Chief Clinical Officer
Gentiva® Health Services
Researchers
Health Management Strategies -- LTPAC/Emergency Department "On-Time" Project Siobhan Sharkey Project Director/Facilitator
Health Management Strategies
Sandy Hudak Project Director/Facilitator
Health Management Strategies
ONC Challenge Grant Awardees
Maryland Health Care Commission -- Facilitating Effective Transitions of Care between Long-Term Care Facilities and Hospital Emergency Departments (ONC Challenge Grant Awardee) Kathleen Francis Chief, HIE
Maryland Health Care Commission
Angela Plunkett Health Policy Analyst, Advanced
Maryland Health Care Commission
David Sharp Director
Maryland Health Care Commission
Massachusetts -- IMPACT Project (ONC Challenge Grant Awardee) Larry Garber, MD Medical Director for Informatics
Fallon Clinic/SAFEHealth
Kris Cyr Project Manager, Health Information Exchange
Massachusetts e-Health Institute
Dawn Heisey-Grove Senior Business Analyst
Massachusetts e-Health Institute
Rick Shoup Director
Massachusetts e-Health Institute
Michele Visconti Senior Consultant
Terrence A. O'Malley, MD Medical Director for Non-Acute Care Services
Partners. HealthCare System

 

TABLE J-2: Participants in the OASIS-C Expert Panel
Sponsoring Organization Panelists
Home Health Experts
Home Care Alliance Karen Carnes RN Vice President, Clinical Ops
Amedisys
Maryann Choi, MD CMO
Harden Healthcare
Leann Darnes, RN Director, Clinical Compliance
LHC Group
Barbara McCann, RN Chief Industry Officer
Interim Healthcare
Mark McDuff Managing Director, IT
Amedisys
Pamela Teenier, RN AVP, Clinical Ops
Gentiva® Health Services
Julie Vandre RN Vice President, Quality & Compliance
Girling Healthcare
Charlotte Weaver, RN Senior Vice President, Chief Clinical Officer
Gentiva® Health Services
Visiting Nurse Service of New York (VNSNY) Sally Sobolewski VNSNY
Integrated Delivery Networks
University of Pittsburgh/ University of Pittsburgh Medical Center (UPMC) Suzanne Keitzer Utilization Supervisor
UPMC-Jefferson Regional Home Health
Chris Lombardo Vice President Reimbursement & Compliance
UPMC-Jefferson Regional Home Health
Nurse Informaticists
Alliance in Nursing (in conjunction with the AMIA Nursing Informatics Working Group) Bonnie Westra, PhD, RN, FAAN Associate Professor, Co-Director ICNP Research Center
University of Minnesota, School of Nursing
Dana Alexander GE Healthcare
Gregory L. Alexander, PhD, MHA, MIS, RN Assistant Professor
University of Missouri-Columbia, Sinclair School of Nursing
Rosemary Kennedy, MBA, RN, FAAN Associate Professor
Thomas Jefferson University, Jefferson School of Nursing
Lori L. Popejoy, PhD, APRN, GNS-BC Assistant Professor
University of Missouri-Columbia, Sinclair School of Nursing
Charlotte Weaver RN, PhD, FAAN Senior Vice President & Chief Clinical Officer
Gentiva® Health Services
Karen S. Martin Omaha System
ONC Challenge Grant Awardees
Maryland Health Care Commission -- Facilitating Effective Transitions of Care between Long-Term Care Facilities and Hospital Emergency Departments (ONC Challenge Grant Awardee) Kathleen Francis Chief, HIE
Maryland Health Care Commission
Angela Plunkett Health Policy Analyst, Advanced
Maryland Health Care Commission
David Sharp Director
Maryland Health Care Commission

 

TABLE J-3: Final Slate of MDS3.0 Data Elements Selected for the Summary Document
ID# Question/Checklist Item Description ID# Question/Checklist Item Description ID# Question/Checklist Item Description
A Section A -- Identification Information
# MDS3.0 Questions/Checklist Items -- 49
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 33
A0200 Type of provider A0310A Type of assessment: OBRA A0500A Resident first name
A0500B Resident middle initial A0500C Resident last name A0500D Resident name suffix
A0600A Social Security Number A0700 Resident Medicaid number A0800 Gender
A0900 Birthdate A1000A Ethnicity: American Indian or Alaska Native A1000B Ethnicity: Asian
A1000C Ethnicity: Black or African American A1000D Ethnicity: Hispanic or Latino A1000E Ethnicity: Native Hawaiian/Pacific Islander
A1000F Ethnicity: White A1100A Does the resident need or want an interpreter A1100B Preferred language
A1200 Marital status A1300A Medical record number A1300C Name by which resident prefers to be addressed
A1300D Lifetime occupation(s) A1550A MR/DD status: Down syndrome A1550B MR/DD status: Autism
A1550C MR/DD status: Epilepsy A1550D MR/DD status: other organic MR/DD condition A1550E MR/DD status: MR/DD with no organic condition
A1600 Entry date (date of admission/reentry in facility) A1700 Type of entry A1800 Entered from
A2000 Discharge date A2100 Discharge status A2300 Assessment reference date
B Section B -- Hearing, Speech, and Vision
# MDS3.0 Questions/Checklist Items -- 8
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 8
B0100 Comatose B0200 Hearing B0300 Hearing aid
B0600 Speech clarity B0700 Makes self understood B0800 Ability to understand others
B1000 Vision B1200 Corrective lenses    
C Section C -- Cognitive Patters
# MDS3.0 Questions/Checklist Items -- 23
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 13
C0500 BIMS res interview: summary score C0700 Staff asmt mental status: short-term memory OK C0800 Staff asmt mental status: long-term memory OK
C0900A Staff asmt mental status: recall current season C0900B Staff asmt mental status: recall location of room C0900C Staff asmt mental status: recall staff names/faces
C0900D Staff asmt mental status: recall in nursing home C1000 Cognitive skills for daily decision making C1300A Signs of delirium: inattention
C1300B Signs of delirium: disorganized thinking C1300C Signs of delirium: altered level of consciousness C1300D Signs of delirium: psychomotor retardation
C1600 Acute onset mental status change        
D Section D -- Mood
# MDS3.0 Questions/Checklist Items -- 43
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 2
D0300 PHQ res: total mood severity score D0600 PHQ staff: total mood score    
E Section E -- Behavior
# MDS3.0 Questions/Checklist Items -- 18
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 14
E0100A Psychosis: hallucinations E0100B Psychosis: delusions E0200A Physical behav symptoms directed toward others
E0200B Verbal behav symptoms directed toward others E0200C Other behav symptoms not directed toward others E0500A Behav symptoms put res at risk for illness/injury
E0500B Behav symptoms interfere with resident care E0500C Behav symptoms interfere with social activities E0600A Behav symptoms put others at risk for injury
E0600B Behav symptoms intrude on privacy of others E0600C Behav symptoms disrupt care or living environment E0800 Rejection of care: presence and frequency
E0900 Wandering: presence and frequency E1100 Change in behavioral or other symptoms    
F Section F -- Preferences for Customary Routine and Activities
# MDS3.0 Questions/Checklist Items -- 40
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 0
G Section G -- Functional Status
# MDS3.0 Questions/Checklist Items -- 36
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 13
G0110A1 Bed mobility: self-performance G0110B1 Transfer: self-performance G0110C1 Walk in room: self-performance
G0110E1 Locomotion on unit: self-performance G0110H1 Eating: self-performance G0110I1 Toilet use: self-performance
G0110J1 Personal hygiene: self-performance G0400A ROM limitation: upper extremity G0400B ROM limitation: lower extremity
G0600A Mobility devices: cane/crutch G0600B Mobility devices: walker G0600C Mobility devices: wheelchair (manual or electric)
G0600D Mobility devices: limb prosthesis        
H Section H -- Bladder and Bowel
# MDS3.0 Questions/Checklist Items -- 49
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 33
H0100A Appliances: indwelling catheter H0100B Appliances: external catheter H0100C Appliances: ostomy
H0100D Appliances: intermittent catheterization H0200C Urinary toileting program: current program/trial H0300 Urinary continence
H0400 Bowel continence H0500 Bowel toileting program being used H0600 Constipation
I Section I -- Active Disease Diagnosis
# MDS3.0 Questions/Checklist Items -- 67
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 66
I0100 Cancer (with or without metastasis) I0200 Anemia I0300 Atrial fibrillation and other dysrhythmias
I0400 Coronary artery disease (CAD) I0500 Deep venous thrombosis (DVT), PE, or PTE I0600 Heart failure
I0700 Hypertension I0800 Orthostatic hypotension I0900 Peripheral vascular disease (PVD) or PAD
I1100 Cirrhosis I1200 Gastroesophageal reflux disease (GERD) or ulcer I1300 Ulcerative colitis, Crohn’s, inflam bowel disease
I1400 Benign prostatic hyperplasia (BPH) I1500 Renal insufficiency, renal failure, ESRD I1550 Neurogenic bladder
I1650 Obstructive uropathy I1700 Multidrug resistant organism (MDRO) I2000 Pneumonia
I2100 Septicemia I2200 Tuberculosis I2300 Urinary tract infection (UTI) (LAST 30 DAYS)
I2400 Viral hepatitis (includes type A, B, C, D, and E) I2500 Wound infection (other than foot) I2900 Diabetes mellitus (DM)
I3100 Hyponatremia I3200 Hyperkalemia I3300 Hyperlipidemia (e.g., hypercholesterolemia)
I3400 Thyroid disorder I3700 Arthritis I3800 Osteoporosis
I3900 Hip fracture I4000 Other fracture I4200 Alzheimer's disease
I4300 Aphasia I4400 Cerebral palsy I4500 Cerebrovascular accident (CVA), TIA, or stroke
I4800 Dementia I4900 Hemiplegia or hemiparesis I5000 Paraplegia
I5100 Quadriplegia I5200 Multiple sclerosis I5250 Huntington's disease
I5300 Parkinson's disease I5350 Tourette's syndrome I5400 Seizure disorder or epilepsy
I5500 Traumatic brain injury (TBI) I5600 Malnutrition (protein, calorie), risk of malnutrit I5700 Anxiety disorder
I5800 Depression (other than bipolar) I5900 Manic depression (bipolar disease) I5950 Psychotic disorder (other than schizophrenia)
I6000 Schizophrenia I6100 Post-traumatic stress disorder (PTSD) I6200 Asthma (COPD) or chronic lung disease
I6300 Respiratory failure I6500 Cataracts, glaucoma, or macular degeneration I8000A Additional active ICD diagnosis 1
I8000B Additional active ICD diagnosis 2 I8000C Additional active ICD diagnosis 3 I8000D Additional active ICD diagnosis 4
I8000E Additional active ICD diagnosis 5 I8000F Additional active ICD diagnosis 6 I8000G Additional active ICD diagnosis 7
I8000H Additional active ICD diagnosis 8 I8000I Additional active ICD diagnosis 9 I8000J Additional active ICD diagnosis 10
J Section J -- Health Conditions
# MDS3.0 Questions/Checklist Items -- 35
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 15
J0100A Pain: been on scheduled pain med regimen J0400 Res pain interview: frequency J0600A Res pain interview: intensity rating scale
J0600B Res pain interview: verbal descriptor scale J1100A Short breath/trouble breathing: with exertion J1100B Short breath/trouble breathing: sitting at rest
J1100C Short breath/trouble breathing: lying flat J1300 Current tobacco use J1400 Prognosis: life expectancy of less than 6 months
J1700A Fall history: fall during month before admission J1700B Fall history: fall 2-6 months before admission J1700C Fall history: fracture from fall 6 month pre admit
J1800 Falls since admit/prior asmt: any falls J1900B Falls since admit/prior asmt: injury (not major) J1900C Falls since admit/prior asmt: major injury
K Section K -- Swallowing/Nutritional Status
# MDS3.0 Questions/Checklist Items -- 15
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 11
K0100A Swallow disorder: loss liquids/solids from mouth K0100B Swallow disorder: holds food in mouth/cheeks K0100C Swallow disorder: cough/choke with meals/meds
K0100D Swallow disorder: difficulty or pain swallowing K0200A Height (in inches) K0200B Weight (in pounds)
K0300 Weight loss K0500A Nutritional approaches: parenteral/IV feeding K0500B Nutritional approaches: feeding tube
K0500C Nutritional approaches: mechanically altered diet K0500D Nutritional approaches: therapeutic diet    
L Section L -- Oral/Dental Status
# MDS3.0 Questions/Checklist Items -- 8
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 6
L0200A Dental: broken or loosely fitting denture L0200B Dental: no natural teeth or tooth fragment(s) L0200C Dental: abnormal mouth tissue
L0200D Dental: cavity or broken natural teeth L0200E Dental: inflamed/bleeding gums or loose teeth L0200F Dental: pain, discomfort, difficulty chewing
M Section M -- Skin Conditions
# MDS3.0 Questions/Checklist Items -- 49
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 38
M0150 Is resident at risk of developing pressure ulcer M0210 Resident has Stage 1 or higher pressure ulcers M0300A Stage 1 pressure ulcers: number present
M0300B1 Stage 2 pressure ulcers: number present M0300B2 Stage 2 pressure ulcers: number at admit/reentry M0300B3 Stage 2 pressure ulcers: date of oldest
M0300C1 Stage 3 pressure ulcers: number present M0300C2 Stage 3 pressure ulcers: number at admit/reentry M0300D1 Stage 4 pressure ulcers: number present
M0300D2 Stage 4 pressure ulcers: number at admit/reentry M0300E1 Unstaged due to dressing: number present M0300E2 Unstaged due to dressing: number at admit/reentry
M0300F1 Unstaged slough/eschar: number present M0300F2 Unstaged slough/eschar: number at admit/reentry M0300G1 Unstageable -- deep tissue: number present
M0300G2 Unstageable -- deep tissue: number at admit/reentry M0610A Stage 3 or 4 pressure ulcer longest length M0610B Stage 3 or 4 pressure ulcer width (same ulcer)
M0610C Stage 3 or 4 pressure ulcer depth (same ulcer) M0800A Worsened since prior asmt: Stage 2 pressure ulcers M0800B Worsened since prior asmt: Stage 3 pressure ulcers
M0800C Worsened since prior asmt: Stage 4 pressure ulcers M1030 Number of venous and arterial ulcers M1040A Other skin probs: infection of the foot
M1040B Other skin probs: diabetic foot ulcer(s) M1040C Other skin probs: other open lesion(s) on the foot M1040D Other skin probs: lesions not ulcers, rashes, cuts
M1040E Other skin probs: surgical wound(s) M1040F Other skin probs: burn(s) (second or third degree) M1200A Skin/ulcer treat: pressure reduce device for chair
M1200B Skin/ulcer treat: pressure reducing device for bed M1200C Skin/ulcer treat: turning/repositioning M1200D Skin/ulcer treat: nutrition/hydration
M1200E Skin/ulcer treat: ulcer care M1200F Skin/ulcer treat: surgical wound care M1200G Skin/ulcer treat: application of dressings
M1200H Skin/ulcer treat: apply ointments/medications M1200I Skin/ulcer treat: apply dressings to feet    
N Section N -- Medications
# MDS3.0 Questions/Checklist Items -- 11
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 8
N0350A Insulin: insulin injections N0400A Medications: antipsychotic N0400B Medications: antianxiety
N0400C Medications: antidepressant N0400D Medications: hypnotic N0400E Medications: anticoagulant
N0400F Medications: antibiotic N0400G Medications: diuretic    
O Section O -- Special Treatments and Procedures
# MDS3.0 Questions/Checklist Items -- 70
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 18
O0100A2 Treatment: chemotherapy -- while resident O0100B2 Treatment: radiation -- while resident O0100C2 Treatment: oxygen therapy -- while resident
O0100D2 Treatment: suctioning -- while resident O0100E2 Treatment: tracheostomy care -- while resident O0100F2 Treatment: vent/respirator -- while resident
O0100G2 Treatment: BIPAP/CPAP -- while resident O0100H2 Treatment: IV medications -- while resident O0100I2 Treatment: transfusions -- while resident
O0100J2 Treatment: dialysis -- while resident O0100K2 Treatment: hospice care -- while resident O0100L2 Treatment: respite care -- while resident
O0100M2 Treatment: isolate/quarantine -- while resident O0250A Was influenza vaccine received O0250B Date influenza vaccine received.
O0250C If influenza vaccine not received, state reason O0300A Is pneumococcal vaccination up to date O0300B If pneumococcal vacc not received, state reason
P Section P -- Restraints
# MDS3.0 Questions/Checklist Items -- 8
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 8
P0100A Restraints used in bed: bed rail P0100B Restraints used in bed: trunk restraint P0100C Restraints used in bed: limb restraint
P0100D Restraints used in bed: other P0100E Restraints in chair/out of bed: trunk restraint P0100F Restraints in chair/out of bed: limb restraint
P0100G Restraints in chair/out of bed: chair stops rising P0100H Restraints in chair/out of bed: other    
Q Section Q -- Participation in Assessment and Goal Setting
# MDS3.0 Questions/Checklist Items -- 10
# MDS3.0 Patient Assessment Summary Questions/Checklist Items -- 1
Q0400B Determination regarding discharge to community        
Z Section Z --
Z0500B Date RN signed assessment as complete        

 

TABLE J-4: Final Slate of OASIS-C Data Elements Selected for the Summary Document
ID# Question/Checklist Item Description ID# Question/Checklist Item Description
PATIENT TRACKING # OASIS-C Questions/Checklist Items -- 25
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 23
M0014_BRANCH_STATE Branch State M0016_BRANCH_ID Branch ID (Optional)
M0018_PHYSICIAN_ID Primary Referring Physician National Provider ID (NPI) M0020_PAT_ID Patient ID Number
M0030_START_CARE_DT Start of Care Date M0032_ROC_DT Resumption of Care Date
M0040_PAT_FNAME Patient's First Name M0040_PAT_MI Patient's Middle Initial
M0040_PAT_LNAME Patient's Last Name M0040_PAT_SUFFIX Patient's Suffix
M0050_PAT_ST Patient State of Residence M0060_PAT_ZIP Patient Zip Code
M0063_MEDICARE_NUM Medicare Number, Including Suffix M0064_SSN Patient's Social Security Number
M0065_MEDICAID_NUM Medicaid Number M0066_PAT_BIRTH_DT Date of Birth
M0069_PAT_GENDER Gender M0140_ETHNIC_AI_AN Race/Ethnicity: American Indian or Alaska Native
M0140_ETHNIC_ASIAN Race/Ethnicity: Asian M0140_ETHNIC_BLACK Race/Ethnicity: Black or African-American
M0140_ETHNIC_HISP Race/Ethnicity: Hispanic or Latino M0140_ETHNIC_NH_PI Race/Ethnicity: Native Hawaiian or Pacific Islander
M0140_ETHNIC_WHITE Race/Ethnicity: White    
CLINICAL RECORD ITEMS # OASIS-C Questions/Checklist Items -- 2
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 2
M0090_INFO_COMPLETED_DT Date Assessment Completed M0100_ASSMT_REASON Reason for Assessment
PATIENT HISTORY AND DIAGNOSES # OASIS-C Questions/Checklist Items -- 38
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 30
M1000 Inpatient discharge facility M1005_INP_DISCHARGE_DT Most Recent Inpatient Discharge Date
M1010 Inpatient Diagnosis M1016 Diagnosis Requiring Regimen Change
M1020_PRIMARY_DIAG_ICD Primary Diagnosis ICD Code M1022_OTH_DIAG1_ICD Other Diagnosis 1: ICD Code
M1022_OTH_DIAG2_ICD Other Diagnosis 2: ICD Code M1022_OTH_DIAG3_ICD Other Diagnosis 3: ICD Code
M1022_OTH_DIAG4_ICD Other Diagnosis 4: ICD Code M1022_OTH_DIAG5_ICD Other Diagnosis 5: ICD Code
M1024_PMT_DIAG_ICD_A3 Case Mix Diagnosis: Primary, Column 3 M1024_PMT_DIAG_ICD_B3 Case Mix Diagnosis: First Secondary, Column 3
M1024_PMT_DIAG_ICD_C3 Case Mix Diagnosis: Second Secondary, Column 3 M1024_PMT_DIAG_ICD_D3 Case Mix Diagnosis: Third Secondary, Column 3
M1024_PMT_DIAG_ICD_E3 Case Mix Diagnosis: Fourth Secondary, Column 3 M1024_PMT_DIAG_ICD_F3 Case Mix Diagnosis: Fifth Secondary, Column 3
M1024_PMT_DIAG_ICD_A4 Case Mix Diagnosis: Primary, Column 4 M1024_PMT_DIAG_ICD_B4 Case Mix Diagnosis: First Secondary, Column 4
M1024_PMT_DIAG_ICD_C4 Case Mix Diagnosis: Second Secondary, Column 4 M1024_PMT_DIAG_ICD_D4 Case Mix Diagnosis: Third Secondary, Column 4
M1024_PMT_DIAG_ICD_E4 Case Mix Diagnosis: Fourth Secondary, Column 4 M1024_PMT_DIAG_ICD_F4 Case Mix Diagnosis: Fifth Secondary, Column 4
M1030 Therapies the patient receives at home M1032 Risk for hospitalization
M1034_PTNT_OVRAL_STUS Patient's Overall Status M1036 Risk factors, either present or past, likely to affect current health status and/or outcome
M1040_INFLNZ_RCVD_AGNCY Influenza Vaccine: Did Patient Receive The Influenza Vaccine M1045_INFLNZ_RSN_NOT_RCVD Influenza Vaccine: Reason Not Received In Agency
M1050_PPV_RCVD_AGNCY Pneumococcal Vaccine: Did Patient Receive The Influenza Vaccine M1055_PPV_RSN_NOT_RCVD_AGNCY Pneumococcal Vaccine: Reason Not Received In Agency
LIVING ARRANGEMENTS # OASIS-C Questions/Checklist Items -- 1
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 1
M1100_PTNT_LVG_STUTN Patient Living Situation    
SENSORY STATUS # OASIS-C Questions/Checklist Items -- 6
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 5
M1200_VISION Sensory Status: Vision M1210_HEARG_ABLTY Ability To Hear
M1220_UNDRSTG_VERBAL_CNTNT Understanding Of Verbal Content In Patient's Own Language M1230_SPEECH Sensory Status: Speech
M1242_PAIN_FREQ_ACTVTY_MVMT Frequency Of Pain Interfering With Patient's Activity Or Movement    
INTEGUMENTARY STATUS # OASIS-C Questions/Checklist Items -- 29
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 24
M1302_RISK_OF_PRSR_ULCR Does This Patient Have A Risk Of Developing PUs M1306_UNHLD_STG2_PRSR_ULCR Patient Has At Least 1 Unhealed PU At Stage 2 Or Higher
M1308_NBR_PRSULC_STG2 No. Pressure Ulcers -- Stage 2 M1308_NBR_STG2_AT_SOC_ROC Number PU Stage 2 At SOC/ROC
M1308_NBR_PRSULC_STG3 No. Pressure Ulcers -- Stage 3 M1308_NBR_STG3_AT_SOC_ROC Number PU Stage 3 At SOC/ROC
M1308_NBR_PRSULC_STG4 No. Pressure Ulcers -- Stage 4 M1308_NBR_STG4_AT_SOC_ROC Number PU Stage 4 At SOC/ROC
M1308_NSTG_DRSG Unstageable Due To Non-removable Dressing Or Device M1308_NSTG_DRSG_SOC_ROC Unstageable Due To Non-removable Dressing Or Device At SOC/ROC
M1308_NSTG_CVRG Unstageable Due To Coverage By Slough Or Eschar M1308_NSTG_CVRG_SOC_ROC Unstageable Due To Coverage By Slough Or Eschar At SOC/ROC
M1308_NSTG_DEEP_TISUE Unstageable Due To Suspected Deep Tissue Injury In Evolution M1308_NSTG_DEEP_TISUE_SOC_ROC Unstageable Due To Suspected Deep Tissue Injury In Evolution At SOC/ROC
M1310_PRSR_ULCR_LNGTH Head To Toe Length Of Stage III Or IV Pu With Largest Area M1312_PRSR_ULCR_WDTH Width At Right Angles Of Stage III Or IV Pu With Largest Area
M1314_PRSR_ULCR_DEPTH Depth Of Stage III Or IV Pu With Largest Area M1320_STUS_PRBLM_PRSR_ULCR Status Of Most Problematic Pressure Ulcer
M1322_NBR_PRSULC_STG1 No. Pressure Ulcers -- Stage 1 M1332_NUM_STAS_ULCR No. Stasis Ulcers
M1334_STUS_PRBLM_STAS_ULCR Status Of Most Problematic Stasis Ulcer M1340_SRGCL_WND_PRSNT Does This Patient Have A Surgical Wound
M1342_STUS_PRBLM_SRGCL_WND Status Of Most Problematic Surgical Wound M1350_LESION_OPEN_WND Has Skin Lesion Or Open Wound
RESPIRATORY STATUS # OASIS-C Questions/Checklist Items -- 2
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 2
M1400_WHEN_DYSPNEIC When Dyspneic M1410 Respiratory treatments utilized at home:
CARDIAC STATUS # OASIS-C Questions/Checklist Items -- 2
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 1
M1500_SYMTM_HRT_FAILR_PTNTS Symptoms In Heart Failure Patients    
ELIMINATION STATUS # OASIS-C Questions/Checklist Items -- 5
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 4
M1600_UTI Treated for Urinary Tract Infection in Past 14 Days M1610_UR_INCONT Urinary Incontinence or Urinary Catheter Present
M1615_INCNTNT_TIMING When Urinary Incontinence Occurs M1620_BWL_INCONT Bowel Incontinence Frequency
NEURO/EMOTIONAL/ BEHAVIORAL STATUS # OASIS-C Questions/Checklist Items -- 9
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 8
M1700_COG_FUNCTION Cognitive Functioning M1710_WHEN_CONFUSED When Confused (Reported or Observed)
M1720_WHEN_ANXIOUS When Anxious (Reported or Observed) M1730_STDZ_DPRSN_SCRNG Has The Patient Been Screened For Depression Using Stdzed Screen Tool
M1730_PHQ2_LACK_INTRST PHQ2 Pfizer Little Interest Or Pleasure In Doing Things M1730_PHQ2_DPRSN PHQ2 Pfizer Feeling Down, Depressed Or Hopeless
M1740 Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed): M1745_BEH_PROB_FREQ Frequency of Behavior Problems
ADL/IADLS # OASIS-C Questions/Checklist Items -- 16
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 12
M1800_CUR_GROOMING Current: Grooming M1810_CUR_DRESS_UPPER Current: Dress Upper Body
M1820_CUR_DRESS_LOWER Current: Dress Lower Body M1830_CRNT_BATHG Current: Bathing
M1840_CUR_TOILTG Current: Toileting M1845_CUR_TOILTG_HYGN Current: Toileting Hygiene
M1850_CUR_TRNSFRNG Current: Transferring M1860_CRNT_AMBLTN Current: Ambulation
M1870_CUR_FEEDING Current: Feeding M1880_CUR_PREP_LT_MEALS Current: Prepare Light Meals
M1890_CUR_PHONE_USE Current: Telephone Use M1910_MLT_FCTR_FALL_RISK_ASMT Has Patient Had A Multi-factor Fall Risk Assessment?
MEDICATIONS # OASIS-C Questions/Checklist Items -- 9
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 2
M2020_CRNT_MGMT_ORAL_MDCTN Current: Management Of Oral Medications M2030_CRNT_MGMT_INJCTN_MDCTN Current: Management Of Injectable Medications
CARE MANAGEMENT # OASIS-C Questions/Checklist Items -- 8
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 8
M2100_CARE_TYPE_SRC_ADL Care Mgmt, Types And Sources Of Assist: ADL M2100_CARE_TYPE_SRC_IADL Care Mgmt, Types And Sources Of Assist: IADL
M2100_CARE_TYPE_SRC_MDCTN Care Mgmt, Types And Sources Of Assist: Medication Admin M2100_CARE_TYPE_SRC_PRCDR Care Mgmt, Types And Sources Of Assist: Med Procs Tx
M2100_CARE_TYPE_SRC_EQUIP Care Mgmt, Types And Sources Of Assist: Equipment M2100_CARE_TYPE_SRC_SPRVSN Care Mgmt, Types And Sources Of Assist: Supervision And Safety
M2100_CARE_TYPE_SRC_ADVCY Care Mgmt, Types And Sources Of Assist: Advocacy Or Facilitation M2110_ADL_IADL_ASTNC_FREQ How Often Recv ADL Or IADL Assistance From Any
THERAPY NEED AND PLANS OF CARE # OASIS-C Questions/Checklist Items -- 8
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 5
M2250_PLAN_SMRY_DBTS_FT_CARE Plan Of Care Synopsis: Diabetic Foot Care M2250_PLAN_SMRY_FALL_PRVNT Plan Of Care Synopsis: Falls Prevention Interventions
M2250_PLAN_SMRY_DPRSN_INTRVTN Plan Of Care Synopsis: Depression Interventions M2250_PLAN_SMRY_PRSULC_PRVNT Plan Of Care Synopsis: PU Prevention
M2250_PLAN_SMRY_PRSULC_TRTMT Plan Of Care Synopsis: PU Moist Treatment    
EMERGENT CARE # OASIS-C Questions/Checklist Items -- 8
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 5
M2300_EMER_USE_AFTR_LAST_ASMT Emergent Care: Use Since Last Oasis Data Collection M2310 Reason for emergent care
DATA ITEMS COLLECTED AT INPATIENT FACILITY ADMISSION OR AGENCY DISCHARGE ONLY # OASIS-C Questions/Checklist Items -- 8
# OASIS-C Patient Assessment Summary Questions/Checklist Items -- 5
M2400_INTRVTN_SMRY_DBTS_FT Intervention Synopsis: Diabetic Foot Care M2400_INTRVTN_SMRY_FALL_PRVNT Intervention Synopsis: Falls Prevention Intervention
M2400_INTRVTN_SMRY_DPRSN Intervention Synopsis: Depression Intervention M2400_INTRVTN_SMRY_PAIN_MNTR Intervention Synopsis: Intervention To Monitor And Mitigate Pain
M2400_INTRVTN_SMRY_PRSULC_PRVN Intervention Synopsis: Intervention To Prevent Pressure Ulcers M2400_INTRVTN_SMRY_PRSULC_WET Intervention Synopsis: Pressure Ulcer Treatment Based On Moist Wound Treatment
M2410_INPAT_FACILITY Inpatient Facility M2420_DSCHRG_DISP Discharge Disposition
M2430 Reason for hospitalization M2440 Reason for nursing home admission
M0903_LAST_HOME_VISIT Date of Last Home Visit M0906_DC_TRAN_DTH_DT Discharge, Transfer, Death Date

 

NOTES

  1. Gage, Barbara, Melissa Morley, Pamela Spain, and Melvin Ingber. Examining Post Acute Care Relationships in an Integrated Hospital System. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2009.

  2. Ibid.

  3. Nawar, Eric, Richard Niska, and Jianmin Xu. “National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary.” Advance Data From Vital and Health Statistics, June 29, 2007.

  4. "Medicare Part B Physician/Supplier Data By Berenson And Eggers Type Of Service Code (BETOS) CY 2008." Centers for Medicare and Medicaid Services. N.p., 2008. Web. July 19, 2010. <http://www.cms.gov/MedicareFeeforSvcPartsAB/Downloads/BETOS08.pdf>.

  5. CMS MDS 2.0 Public Quality Indicator and Resident Reports -- Assessment Counts Report. (2010, Third Quarter). Retrieved from http://www.cms.gov/MDSPubQIandResRep/05_assesscntreport.asp.

  6. GE and KeyHIEExpand Health Information Exchange Collaboration: Next Stage of Project to Enhance Chronic Disease Management Model. (January 11, 2011). Retrieved from https://www.keystonebeaconcommunity.org/news/2011/01/ge-keyhie-expand-health-information-exchange.cfm.

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