Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. MDS Summary -- Model Of Meaning

12/01/2011

[NOTE: This table was split in half because of the size for HTML & PDF versions.]

Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
A     Section A - Identification Information N/A    
  A0200   Type of provider TRUE    
  A0200 1 Nursing home (SNF/NF) TRUE    
  A0200 2 Swing bed TRUE    
  A0310A   Type of assessment: OBRA TRUE 99 - Not OBRA required assessment/tracking  
  A0310A 1 Admission assessment (required by day 14) TRUE    
  A0310A 2 Quarterly review assessment TRUE    
  A0310A 3 Annual assessment TRUE    
  A0310A 4 Significant change in status assessment TRUE    
  A0310A 5 Significant correction to prior comprehensive assessment TRUE    
  A0310A 6 Significant correction to prior quarterly assessment TRUE    
  A0500A   Resident first name TRUE    
  A0500B   Resident middle initial TRUE    
  A0500C   Resident last name TRUE    
  A0500D   Resident name suffix TRUE    
  A0600A   Social Security Number TRUE    
  A0700   Resident Medicaid number TRUE    
  A0800   Gender TRUE    
  A0800 1 Male TRUE    
  A0800 2 Female TRUE    
  A0900   Birthdate TRUE    
  A1000A   Ethnicity: American Indian or Alaska Native TRUE   *ONC Final Rule (7/28/2010) requires use of the Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, October 30, 1997. This is not a vocabulary.
*HITSP Component C-32 ( HITSP Summary Documents Using HL7 Continuity of Care Document (CCD)) requires use of the CDC Race and Ethnicity vocabulary for reporting race and ethnicity (see Column Q).
*See DSTU for details on representation of Race/Ethnicity data.
  A1000B   Ethnicity: Asian TRUE    
  A1000C   Ethnicity: Black or African American TRUE    
  A1000D   Ethnicity: Hispanic or Latino TRUE    
  A1000E   Ethnicity: Native Hawaiian/Pacific Islander TRUE    
  A1000F   Ethnicity: White TRUE    
  A1100A   Does the resident need or want an interpreter TRUE 0 - No;
9 - Unable to determine
 
  A1100A 1 Yes TRUE    
  A1100B   Preferred language TRUE    
  A1200   Marital status TRUE    
  A1200 1 Never married TRUE    
  A1200 2 Married TRUE    
  A1200 3 Widowed TRUE    
  A1200 4 Separated TRUE    
  A1200 5 Divorced TRUE    
  A1300A MDCL_REC_NUM Medical record number TRUE    
  A1300C PREFRD_NAME Name by which resident prefers to be addressed TRUE    
  A1300D   Lifetime occupation(s) TRUE    
  A1550A   MR/DD status: Down syndrome TRUE    
  A1550B   MR/DD status: Autism TRUE    
  A1550C   MR/DD status: Epilepsy TRUE    
  A1550D   MR/DD status: other organic MR/DD condition TRUE    
  A1550E   MR/DD status: MR/DD with no organic condition TRUE    
  A1600   Entry date (date of admission/reentry in facility) TRUE    
  A1700   Type of entry TRUE    
  A1700 1 Admission TRUE    
  A1700 2 Reentry TRUE    
  A1800   Entered from TRUE 99 - Other  
  A1800 1 Community (private home/apt., board/care, assisted living, group home) TRUE    
  A1800 2 Another nursing home or swing bed TRUE    
  A1800 3 Acute hospital TRUE    
  A1800 4 Psychiatric hospital TRUE    
  A1800 5 Inpatient rehabilitation facility TRUE    
  A1800 6 MR/DD facility TRUE    
  A1800 7 Hospice TRUE    
  A2000   Discharge date TRUE    
  A2100   Discharge status TRUE 99 - Other  
  A2100 1 Community (private home/apt., board/care, assisted living, group home) TRUE    
  A2100 2 Another nursing home or swing bed TRUE    
  A2100 3 Acute hospital TRUE    
  A2100 4 Psychiatric hospital TRUE    
  A2100 5 Inpatient rehabilitation facility TRUE    
  A2100 6 MR/DD facility TRUE    
  A2100 7 Hospice TRUE    
  A2100 8 Deceased TRUE    
  A2300   Assessment reference date TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
B     Section B - Hearing, Speech, and Vision N/A    
  B0100   Comatose TRUE 0 - No  
  B0100 1 Yes TRUE    
  B0200   Hearing TRUE    
  B0200 0 Adequate - no difficulty in normal conversation, social interaction, listening to TV TRUE    
  B0200 1 Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy) TRUE    
  B0200 2 Moderate difficulty - speaker has to increase volume and speak distinctly TRUE    
  B0200 3 Highly impaired - absence of useful hearing TRUE    
  B0300   Hearing aid TRUE 0 - No  
  B0300 1 Yes TRUE    
  B0600   Speech clarity TRUE    
  B0600 0 Clear speech - distinct intelligible words TRUE    
  B0600 1 Unclear speech - slurred or mumbled words TRUE    
  B0600 2 No speech - absence of spoken words TRUE    
  B0700   Makes self understood TRUE    
  B0700 0 Understood TRUE    
  B0700 1 Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time TRUE    
  B0700 2 Sometimes understood - ability is limited to making concrete requests TRUE    
  B0700 3 Rarely/never understood TRUE    
  B0800   Ability to understand others TRUE    
  B0800 0 Understands - clear comprehension TRUE    
  B0800 1 Usually understands - misses some part/intent of message but comprehends most conversation TRUE    
  B0800 2 Sometimes understands - responds adequately to simple, direct communication only TRUE    
  B0800 3 Rarely/never understands TRUE    
  B1000   Vision TRUE    
  B1000 0 Adequate - sees fine detail, including regular print in newspapers/books TRUE    
  B1000 1 Impaired - sees large print, but not regular print in newspapers/books TRUE    
  B1000 2 Moderately Impaired - limited vision; not able to see newspaper headlines but can identify objects TRUE    
  B1000 3 Highly impaired - object identification in question, but eyes appear to follow objects TRUE    
  B1000 4 Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects TRUE    
  B1200   Corrective lenses TRUE 0 - No  
  B1200 1 Yes TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
C     Section C - Cognitive Patterns N/A    
  C0500   BIMS res interview: summary score TRUE    
  C0700   Staff asmt mental status: short-term memory OK TRUE    
  C0700 0 Memory OK TRUE    
  C0700 1 Memory problem TRUE    
  C0800   Staff asmt mental status: long-term memory OK TRUE    
  C0800 0 Memory OK TRUE    
  C0800 1 Memory problem TRUE    
  C0900A   Staff asmt mental status: recall current season TRUE    
  C0900B   Staff asmt mental status: recall location of room TRUE    
  C0900C   Staff asmt mental status: recall staff names/faces TRUE    
  C0900D   Staff asmt mental status: recall in nursing home TRUE    
  C1000   Cognitive skills for daily decision making TRUE    
  C1000 0 Independent - decisions consistent/reasonable TRUE    
  C1000 1 Modified independence - some difficulty in new situations only TRUE    
  C1000 2 Moderately impaired - decisions poor; cues/supervision required TRUE    
  C1000 3 Severely impaired - never/rarely made decisions TRUE    
  C1300A   Signs of delirium: inattention TRUE 0 - Behavior not present  
  C1300A 1 Behavior continuously present, does not fluctuate TRUE    
  C1300A 2 Behavior present, fluctuates (comes and goes, changes in severity) TRUE    
  C1300B   Signs of delirium: disorganized thinking TRUE 0 - Behavior not present  
  C1300B 1 Behavior continuously present, does not fluctuate TRUE    
  C1300B 2 Behavior present, fluctuates (comes and goes, changes in severity) TRUE    
  C1300C   Signs of delirium: altered level of consciousness TRUE 0 - Behavior not present  
  C1300C 1 Behavior continuously present, does not fluctuate TRUE    
  C1300C 2 Behavior present, fluctuates (comes and goes, changes in severity) TRUE    
  C1300D   Signs of delirium: psychomotor retardation TRUE 0 - Behavior not present  
  C1300D 1 Behavior continuously present, does not fluctuate TRUE    
  C1300D 2 Behavior present, fluctuates (comes and goes, changes in severity) TRUE    
  C1600   Acute onset mental status change TRUE 0 - No  
  C1600 1 Yes TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
D     Section D - Mood N/A    
  D0300   PHQ res: total mood severity score TRUE    
  D0600   PHQ staff: total mood score TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
E     Section E - Behavior N/A    
  E0100A   Psychosis: hallucinations TRUE    
  E0100B   Psychosis: delusions TRUE    
  E0200A   Physical behav symptoms directed toward others TRUE 0 - Behavior not exhibited  
  E0200A 1 Behavior of this type occurred 1 to 3 days TRUE    
  E0200A 2 Behavior of this type occurred 4 to 6 days, but less than daily TRUE    
  E0200A 3 Behavior of this type occurred daily TRUE    
  E0200B   Verbal behav symptoms directed toward others TRUE 0 - Behavior not exhibited  
  E0200B 1 Behavior of this type occurred 1 to 3 days TRUE    
  E0200B 2 Behavior of this type occurred 4 to 6 days, but less than daily TRUE    
  E0200B 3 Behavior of this type occurred daily TRUE    
  E0200C   Other behav symptoms not directed toward others TRUE 0 - Behavior not exhibited  
  E0200C 1 Behavior of this type occurred 1 to 3 days TRUE    
  E0200C 2 Behavior of this type occurred 4 to 6 days, but less than daily TRUE    
  E0200C 3 Behavior of this type occurred daily TRUE    
  E0500A   Behav symptoms put res at risk for illness/injury TRUE 0 - No  
  E0500A 1 Yes TRUE    
  E0500B   Behav symptoms interfere with resident care TRUE 0 - No  
  E0500B 1 Yes TRUE    
  E0500C   Behav symptoms interfere with social activities TRUE 0 - No  
  E0500C 1 Yes TRUE    
  E0600A   Behav symptoms put others at risk for injury TRUE 0 - No  
  E0600A 1 Yes TRUE    
  E0600B   Behav symptoms intrude on privacy of others TRUE 0 - No  
  E0600B 1 Yes TRUE    
  E0600C   Behav symptoms disrupt care or living environment TRUE 0 - No  
  E0600C 1 Yes TRUE    
  E0800   Rejection of care: presence and frequency TRUE 0 - Behavior not exhibited  
  E0800 1 Behavior of this type occurred 1 to 3 days TRUE    
  E0800 2 Behavior of this type occurred 4 to 6 days, but less than daily TRUE    
  E0800 3 Behavior of this type occurred daily TRUE    
  E0900   Wandering: presence and frequency TRUE 0 - Behavior not exhibited  
  E0900 1 Behavior of this type occurred 1 to 3 days TRUE    
  E0900 2 Behavior of this type occurred 4 to 6 days, but less than daily TRUE    
  E0900 3 Behavior of this type occurred daily TRUE    
  E1100   Change in behavioral or other symptoms TRUE 0 - Same;
9 - N/A because no prior MDS assessment
 
  E1100 1 Improved TRUE    
  E1100 2 Worse TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
F     Section F - Preferences for Customary Routine and Activities N/A    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
G     Section G - Functional Status N/A    
  G0110A1   Bed mobility: self-performance TRUE    
  G0110A1 0 Independent - no help or staff oversight at any time TRUE    
  G0110A1 1 Supervision - oversight, encouragement or cueing TRUE    
  G0110A1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance TRUE    
  G0110A1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support TRUE    
  G0110A1 4 Total dependence - full staff performance every time during entire 7-day period TRUE    
  G0110A1 7 Activity occurred only once or twice - activity did occur but only once or twice. TRUE    
  G0110A1 8 Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period TRUE    
  G0110B1   Transfer: self-performance TRUE    
  G0110B1 0 Independent - no help or staff oversight at any time TRUE    
  G0110B1 1 Supervision - oversight, encouragement or cueing TRUE    
  G0110B1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance TRUE    
  G0110B1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support TRUE    
  G0110B1 4 Total dependence - full staff performance every time during entire 7-day period TRUE    
  G0110B1 7 Activity occurred only once or twice - activity did occur but only once or twice. TRUE    
  G0110B1 8 Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period TRUE    
  G0110C1   Walk in room: self-performance TRUE    
  G0110C1 0 Independent - no help or staff oversight at any time TRUE    
  G0110C1 1 Supervision - oversight, encouragement or cueing TRUE    
  G0110C1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance TRUE    
  G0110C1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support TRUE    
  G0110C1 4 Total dependence - full staff performance every time during entire 7-day period TRUE    
  G0110C1 7 Activity occurred only once or twice - activity did occur but only once or twice. TRUE    
  G0110C1 8 Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period TRUE    
  G0110E1   Locomotion on unit: self-performance TRUE    
  G0110E1 0 Independent - no help or staff oversight at any time TRUE    
  G0110E1 1 Supervision - oversight, encouragement or cueing TRUE    
  G0110E1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance TRUE    
  G0110E1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support TRUE    
  G0110E1 4 Total dependence - full staff performance every time during entire 7-day period TRUE    
  G0110E1 7 Activity occurred only once or twice - activity did occur but only once or twice. TRUE    
  G0110E1 8 Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period TRUE    
  G0110H1   Eating: self-performance TRUE    
  G0110H1 0 Independent - no help or staff oversight at any time TRUE    
  G0110H1 1 Supervision - oversight, encouragement or cueing TRUE    
  G0110H1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance TRUE    
  G0110H1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support TRUE    
  G0110H1 4 Total dependence - full staff performance every time during entire 7-day period TRUE    
  G0110H1 7 Activity occurred only once or twice - activity did occur but only once or twice. TRUE    
  G0110H1 8 Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period TRUE    
  G0110I1   Toilet use: self-performance TRUE    
  G0110I1 0 Independent - no help or staff oversight at any time TRUE    
  G0110I1 1 Supervision - oversight, encouragement or cueing TRUE    
  G0110I1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance TRUE    
  G0110I1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support TRUE    
  G0110I1 4 Total dependence - full staff performance every time during entire 7-day period TRUE    
  G0110I1 7 Activity occurred only once or twice - activity did occur but only once or twice. TRUE    
  G0110I1 8 Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period TRUE    
  G0110J1   Personal hygiene: self-performance TRUE    
  G0110J1 0 Independent - no help or staff oversight at any time TRUE    
  G0110J1 1 Supervision - oversight, encouragement or cueing TRUE    
  G0110J1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance TRUE    
  G0110J1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support TRUE    
  G0110J1 4 Total dependence - full staff performance every time during entire 7-day period TRUE    
  G0110J1 7 Activity occurred only once or twice - activity did occur but only once or twice. TRUE    
  G0110J1 8 Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period TRUE    
  G0400A   ROM limitation: upper extremity TRUE 0 - No impairment  
  G0400A 1 Impairment on one side TRUE    
  G0400A 2 Impairment on both sides TRUE    
  G0400B   ROM limitation: lower extremity TRUE 0 - No impairment  
  G0400B 1 Impairment on one side TRUE    
  G0400B 2 Impairment on both sides TRUE    
  G0600A   Mobility devices: cane/crutch TRUE    
  G0600B   Mobility devices: walker TRUE    
  G0600C   Mobility devices: wheelchair (manual or electric) TRUE    
  G0600D   Mobility devices: limb prosthesis TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
H     Section H - Bladder and Bowel N/A    
  H0100A   Appliances: indwelling catheter TRUE    
  H0100B   Appliances: external catheter TRUE    
  H0100C   Appliances: ostomy TRUE    
  H0100D   Appliances: intermittent catheterization TRUE    
  H0200C   Urinary toileting program: current program/trial TRUE 0 - No  
  H0200C 1 Yes TRUE    
  H0300   Urinary continence TRUE    
  H0300 0 Always continent TRUE    
  H0300 1 Occasionally incontinent (less than 7 episodes of incontinence) TRUE    
  H0300 2 Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) TRUE    
  H0300 3 Always incontinent (no episodes of continent voiding) TRUE    
  H0300 9 Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for entire 7 days TRUE    
  H0400   Bowel continence TRUE    
  H0400 0 Always continent TRUE    
  H0400 1 Occasionally incontinent (one episode of bowel incontinence) TRUE    
  H0400 2 Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) TRUE    
  H0400 3 Always incontinent (no episodes of continent bowel movements) TRUE    
  H0400 9 Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days TRUE    
  H0500   Bowel toileting program being used TRUE 0 - No  
  H0500 1 Yes TRUE    
  H0600   Constipation TRUE 0 - No  
  H0600 1 Yes TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
I     Section I - Active Disease Diagnosis N/A    
  I0100   Cancer (with or without metastasis) TRUE    
  I0200   Anemia TRUE    
  I0300   Atrial fibrillation and other dysrhythmias TRUE    
  I0400   Coronary artery disease (CAD) TRUE    
  I0500   Deep venous thrombosis (DVT), PE, or PTE TRUE    
  I0600   Heart failure TRUE    
  I0700   Hypertension TRUE    
  I0800   Orthostatic hypotension TRUE    
  I0900   Peripheral vascular disease (PVD) or PAD TRUE    
  I1100   Cirrhosis TRUE    
  I1200   Gastroesophageal reflux disease (GERD) or ulcer TRUE    
  I1300   Ulcerative colitis, Crohn’s, inflam bowel disease TRUE    
  I1400   Benign prostatic hyperplasia (BPH) TRUE    
  I1500   Renal insufficiency, renal failure, ESRD TRUE    
  I1550   Neurogenic bladder TRUE    
  I1650   Obstructive uropathy TRUE    
  I1700   Multidrug resistant organism (MDRO) TRUE    
  I2000   Pneumonia TRUE    
  I2100   Septicemia TRUE    
  I2200   Tuberculosis TRUE    
  I2300   Urinary tract infection (UTI) (LAST 30 DAYS) TRUE    
  I2400   Viral hepatitis (includes type A, B, C, D, and E) TRUE    
  I2500   Wound infection (other than foot) TRUE    
  I2900   Diabetes mellitus (DM) TRUE    
  I3100   Hyponatremia TRUE    
  I3200   Hyperkalemia TRUE    
  I3300   Hyperlipidemia (e.g., hypercholesterolemia) TRUE    
  I3400   Thyroid disorder TRUE    
  I3700   Arthritis TRUE    
  I3800   Osteoporosis TRUE    
  I3900   Hip fracture TRUE    
  I4000   Other fracture TRUE    
  I4200   Alzheimer's disease TRUE    
  I4300   Aphasia TRUE    
  I4400   Cerebral palsy TRUE    
  I4500   Cerebrovascular accident (CVA), TIA, or stroke TRUE    
  I4800   Dementia TRUE    
  I4900   Hemiplegia or hemiparesis TRUE    
  I5000   Paraplegia TRUE    
  I5100   Quadriplegia TRUE    
  I5200   Multiple sclerosis TRUE    
  I5250   Huntington's disease TRUE    
  I5300   Parkinson's disease TRUE    
  I5350   Tourette's syndrome TRUE    
  I5400   Seizure disorder or epilepsy TRUE    
  I5500   Traumatic brain injury (TBI) TRUE    
  I5600   Malnutrition (protein, calorie), risk of malnutrit TRUE    
  I5700   Anxiety disorder TRUE    
  I5800   Depression (other than bipolar) TRUE    
  I5900   Manic depression (bipolar disease) TRUE    
  I5950   Psychotic disorder (other than schizophrenia) TRUE    
  I6000   Schizophrenia TRUE    
  I6100   Post-traumatic stress disorder (PTSD) TRUE    
  I6200   Asthma (COPD) or chronic lung disease TRUE    
  I6300   Respiratory failure TRUE    
  I6500   Cataracts, glaucoma, or macular degeneration TRUE    
  I8000A   Additional active ICD diagnosis 1 TRUE    
  I8000B   Additional active ICD diagnosis 2 TRUE    
  I8000C   Additional active ICD diagnosis 3 TRUE    
  I8000D   Additional active ICD diagnosis 4 TRUE    
  I8000E   Additional active ICD diagnosis 5 TRUE    
  I8000F   Additional active ICD diagnosis 6 TRUE    
  I8000G   Additional active ICD diagnosis 7 TRUE    
  I8000H   Additional active ICD diagnosis 8 TRUE    
  I8000I   Additional active ICD diagnosis 9 TRUE    
  I8000J   Additional active ICD diagnosis 10 TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
J     Section J - Health Conditions N/A    
  J0100A   Pain: been on scheduled pain med regimen TRUE 0 - No  
  J0100A 1 Yes TRUE    
  J0400   Res pain interview: frequency TRUE 9 - Unable to answer  
  J0400 1 Almost constantly TRUE    
  J0400 2 Frequently TRUE    
  J0400 3 Occasionally TRUE    
  J0400 4 Rarely TRUE    
  J0600A   Res pain interview: intensity rating scale TRUE    
  J0600B   Res pain interview: verbal descriptor scale TRUE 9 - Unable to answer  
  J0600B 1 Mild TRUE    
  J0600B 2 Moderate TRUE    
  J0600B 3 Severe TRUE    
  J0600B 4 Very severe, horrible TRUE    
  J1100A   Short breath/trouble breathing: with exertion TRUE    
  J1100B   Short breath/trouble breathing: sitting at rest TRUE    
  J1100C   Short breath/trouble breathing: lying flat TRUE    
  J1300   Current tobacco use TRUE 0 - No  
  J1300 1 Yes TRUE    
  J1400   Prognosis: life expectancy of less than 6 months TRUE 0 - No  
  J1400 1 Yes TRUE    
  J1700A   Fall history: fall during month before admission TRUE 0 - No;
9 - Unable to determine
 
  J1700A 1 Yes TRUE    
  J1700B   Fall history: fall 2-6 months before admission TRUE 0 - No;
9 - Unable to determine
 
  J1700B 1 Yes TRUE    
  J1700C   Fall history: fracture from fall 6 month pre admit TRUE 0 - No;
9 - Unable to determine
 
  J1700C 1 Yes TRUE    
  J1800   Falls since admit/prior asmt: any falls TRUE 0 - No  
  J1800 1 Yes TRUE    
  J1900B   Falls since admit/prior asmt: injury (not major) TRUE 0 - None  
  J1900B 1 One TRUE    
  J1900B 2 Two or more TRUE    
  J1900C   Falls since admit/prior asmt: major injury TRUE 0 - None  
  J1900C 1 One TRUE    
  J1900C 2 Two or more TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
K     Section K - Swallowing/ Nutritional Status N/A    
  K0100A   Swallow disorder: loss liquids/solids from mouth TRUE    
  K0100B   Swallow disorder: holds food in mouth/cheeks TRUE    
  K0100C   Swallow disorder: cough/choke with meals/meds TRUE    
  K0100D   Swallow disorder: difficulty or pain swallowing TRUE    
  K0200A   Height (in inches) TRUE    
  K0200B   Weight (in pounds) TRUE    
  K0300   Weight loss TRUE 0 - No, or unknown  
  K0300 1 Yes, on physician - prescribed weight - loss regimen TRUE    
  K0300 2 Yes, not on physician - prescribed weight - loss regimen TRUE    
  K0500A   Nutritional approaches: parenteral /IV feeding TRUE    
  K0500B   Nutritional approaches: feeding tube TRUE    
  K0500C   Nutritional approaches: mechanically altered diet TRUE    
  K0500D   Nutritional approaches: therapeutic diet TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
L     Section L - Oral/Dental Status N/A    
  L0200A   Dental: broken or loosely fitting denture TRUE    
  L0200B   Dental: no natural teeth or tooth fragment(s) TRUE    
  L0200C   Dental: abnormal mouth tissue TRUE    
  L0200D   Dental: cavity or broken natural teeth TRUE    
  L0200E   Dental: inflamed/bleeding gums or loose teeth TRUE    
  L0200F   Dental: pain, discomfort, difficulty chewing TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
M     Section M - Skin Conditions N/A    
  M0150   Is resident at risk of developing pressure ulcer TRUE 0 - No  
  M0150 1 Yes TRUE    
  M0210   Resident has Stage 1 or higher pressure ulcers TRUE 0 - No  
  M0210 1 Yes TRUE    
  M0300A   Stage 1 pressure ulcers: number present TRUE 0  
  M0300B1   Stage 2 pressure ulcers: number present TRUE 0  
  M0300B2   Stage 2 pressure ulcers: number at admit/reentry TRUE 0  
  M0300B3   Stage 2 pressure ulcers: date of oldest TRUE    
  M0300C1   Stage 3 pressure ulcers: number present TRUE 0  
  M0300C2   Stage 3 pressure ulcers: number at admit/reentry TRUE 0  
  M0300D1   Stage 4 pressure ulcers: number present TRUE 0  
  M0300D2   Stage 4 pressure ulcers: number at admit/reentry TRUE 0  
  M0300E1   Unstaged due to dressing: number present TRUE 0  
  M0300E2   Unstaged due to dressing: number at admit/reentry TRUE 0  
  M0300F1   Unstaged slough/eschar: number present TRUE 0  
  M0300F2   Unstaged slough/eschar: number at admit/reentry TRUE 0  
  M0300G1   Unstageable - deep tissue: number present TRUE 0  
  M0300G2   Unstageable - deep tissue: number at admit/reentry TRUE 0  
  M0610A   Stage 3 or 4 pressure ulcer longest length TRUE    
  M0610B   Stage 3 or 4 pressure ulcer width (same ulcer) TRUE    
  M0610C   Stage 3 or 4 pressure ulcer depth (same ulcer) TRUE    
  M0800A   Worsened since prior asmt: Stage 2 pressure ulcers TRUE 0  
  M0800B   Worsened since prior asmt: Stage 3 pressure ulcers TRUE 0  
  M0800C   Worsened since prior asmt: Stage 4 pressure ulcers TRUE 0  
  M1030   Number of venous and arterial ulcers TRUE 0  
  M1040A   Other skin probs: infection of the foot TRUE    
  M1040B   Other skin probs: diabetic foot ulcer(s) TRUE    
  M1040C   Other skin probs: other open lesion(s) on the foot TRUE    
  M1040D   Other skin probs: lesions not ulcers, rashes, cuts TRUE    
  M1040E   Other skin probs: surgical wound(s) TRUE    
  M1040F   Other skin probs: burn(s) (second or third degree) TRUE    
  M1200A   Skin/ulcer treat: pressure reduce device for chair TRUE    
  M1200B   Skin/ulcer treat: pressure reducing device for bed TRUE    
  M1200C   Skin/ulcer treat: turning/repositioning TRUE    
  M1200D   Skin/ulcer treat: nutrition/hydration TRUE    
  M1200E   Skin/ulcer treat: ulcer care TRUE    
  M1200F   Skin/ulcer treat: surgical wound care TRUE    
  M1200G   Skin/ulcer treat: application of dressings TRUE    
  M1200H   Skin/ulcer treat: apply ointments/medications TRUE    
  M1200I   Skin/ulcer treat: apply dressings to feet TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
N     Section N - Medications N/A    
  N0350A   Insulin: insulin injections TRUE    
  N0400A   Medications: antipsychotic TRUE    
  N0400B   Medications: antianxiety TRUE    
  N0400C   Medications: antidepressant TRUE    
  N0400D   Medications: hypnotic TRUE    
  N0400E   Medications: anticoagulant TRUE    
  N0400F   Medications: antibiotic TRUE    
  N0400G   Medications: diuretic TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
O     Section O - Special Treatments and Procedures N/A    
  O0100A2   Treatment: chemotherapy - while resident TRUE    
  O0100B2   Treatment: radiation - while resident TRUE    
  O0100C2   Treatment: oxygen therapy - while resident TRUE    
  O0100D2   Treatment: suctioning - while resident TRUE    
  O0100E2   Treatment: tracheostomy care - while resident TRUE    
  O0100F2   Treatment: vent/respirator - while resident TRUE    
  O0100G2   Treatment: BIPAP/CPAP - while resident TRUE    
  O0100H2   Treatment: IV medications - while resident TRUE    
  O0100I2   Treatment: transfusions - while resident TRUE    
  O0100J2   Treatment: dialysis - while resident TRUE    
  O0100K2   Treatment: hospice care - while resident TRUE    
  O0100L2   Treatment: respite care - while resident TRUE    
  O0100M2   Treatment: isolate/quarantine - while resident TRUE    
  O0250A   Was influenza vaccine received TRUE    
  O0250A 0 No TRUE    
  O0250A 1 Yes TRUE    
  O0250B   Date influenza vaccine received. TRUE    
  O0250C   If influenza vaccine not received, state reason TRUE 9 - None of the above  
  O0250C 1 Resident not in facility during this year's flu season TRUE    
  O0250C 2 Received outside of this facility TRUE    
  O0250C 3 Not eligible - medical contraindication TRUE    
  O0250C 4 Offered and declined TRUE    
  O0250C 5 Not offered TRUE    
  O0250C 6 Inability to obtain vaccine due to a declared shortage TRUE    
  O0300A   Is pneumococcal vaccination up to date TRUE    
  O0300A 0 No TRUE    
  O0300A 1 Yes TRUE    
  O0300B   If pneumococcal vacc not received, state reason TRUE    
  O0300B 1 Not eligible - medical contraindication TRUE    
  O0300B 2 Offered and declined TRUE    
  O0300B 3 Not offered TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
P     Section P - Restraints N/A    
  P0100A   Restraints used in bed: bed rail TRUE 0 - Not used  
  P0100A 1 Used less than daily TRUE    
  P0100A 2 Used daily TRUE    
  P0100B   Restraints used in bed: trunk restraint TRUE 0 - Not used  
  P0100B 1 Used less than daily TRUE    
  P0100B 2 Used daily TRUE    
  P0100C   Restraints used in bed: limb restraint TRUE 0 - Not used  
  P0100C 1 Used less than daily TRUE    
  P0100C 2 Used daily TRUE    
  P0100D   Restraints used in bed: other TRUE 0 - Not used  
  P0100D 1 Used less than daily TRUE    
  P0100D 2 Used daily TRUE    
  P0100E   Restraints in chair/out of bed: trunk restraint TRUE 0 - Not used  
  P0100E 1 Used less than daily TRUE    
  P0100E 2 Used daily TRUE    
  P0100F   Restraints in chair/out of bed: limb restraint TRUE 0 - Not used  
  P0100F 1 Used less than daily TRUE    
  P0100F 2 Used daily TRUE    
  P0100G   Restraints in chair/out of bed: chair stops rising TRUE 0 - Not used  
  P0100G 1 Used less than daily TRUE    
  P0100G 2 Used daily TRUE    
  P0100H   Restraints in chair/out of bed: other TRUE 0 - Not used  
  P0100H 1 Used less than daily TRUE    
  P0100H 2 Used daily TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
Q     Section Q - Participation in Assessment and Goal Setting N/A    
  Q0400B   Determination regarding discharge to community TRUE    
  Q0400B 0 Determination not made TRUE    
  Q0400B 1 Discharge to community determined to be feasible TRUE    
  Q0400B 2 Discharge to community determined to be not feasible TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
T     Therapy Supplement for Medicare PPS N/A    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
V       N/A    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
X       N/A    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
Z     Assessment Administration N/A    
  Z0500B   Date RN signed assessment as complete TRUE    
Section CMS Question ID Answer CMS Description
Light Orange Shading Indicates Start of New Question per CMS Data Dictionary
FINAL SUMMARY ITEM Response(s) Triggering Omission of MDS Question from Summary General Guidance on Mapping
OTHER       N/A    

 

Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
A            
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
             
             
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
             
             
             
             
             
             
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
             
             
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
ETHNICITY PATTERN         1002-5  
ETHNICITY PATTERN         2028-9  
ETHNICITY PATTERN         2054-5  
ETHNICITY PATTERN         2135-2  
ETHNICITY PATTERN         2076-8  
ETHNICITY PATTERN         2106-3  
ASSERTION PATTERN            
Assertion pattern 315594003 interpreter needed (finding)        
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
             
             
             
             
             
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
Assertion pattern 41040004 complete trisomy 21 syndrome (disorder)        
Assertion pattern 408856003 autistic disorder (disorder)        
Assertion pattern 84757009 epilepsy (disorder)        
  Concept Not Mapped (Reason #5) - Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT          
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
             
             
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
             
             
             
             
             
             
             
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
             
             
             
             
             
             
             
             
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
B            
ASSERTION PATTERN            
Assertion pattern 371632003 coma (disorder)        
ASSERTION PATTERN            
Assertion pattern 162339002 hearing normal (finding)        
Assertion pattern 162340000 hearing difficulty (finding)        
Assertion pattern 425091001 difficulty hearing normal speech tones (finding)        
Assertion pattern 306972000 unable to hear loud voice (finding)        
ASSERTION PATTERN            
Assertion pattern 285055002 does use hearing aid (finding)        
ASSERTION PATTERN            
Assertion pattern 286296002 does articulate clearly (finding)        
Assertion pattern 286298001 does not articulate clearly (finding)        
Assertion pattern 286371003 does not speak (finding)        
QUESTION/ANSWER PATTERN 288743004 ability to make self understood (observable entity)        
Question/Answer pattern 288746007 does make self understood (finding)        
Question/Answer pattern 288748008 difficulty making self understood (finding)        
Question/Answer pattern 288748008 difficulty making self understood (finding)        
Question/Answer pattern 288747003 does not make self understood (finding)        
QUESTION/ANSWER PATTERN 395659009 ability to comprehend (observable entity)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 64270008 disturbance of understanding (finding)        
Question/Answer pattern 64270008 disturbance of understanding (finding)        
Question/Answer pattern 53314000 akatamathesia (finding)        
QUESTION/ANSWER PATTERN 415823006 vision observable (observable entity)        
Question/Answer pattern 45089002 normal vision (finding)        
Question/Answer pattern 424883003 difficulty seeing small print (finding)        
Question/Answer pattern 285163004 able to recognize objects by sight (finding)        
Question/Answer pattern 170728008 poor visual acuity (finding)        
Question/Answer pattern 397541004 severe visual impairment (disorder)        
ASSERTION PATTERN            
Assertion pattern 365237006 finding related to ability to use appliances for sensory impairment (finding)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
C            
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
ASSERTION PATTERN            
Assertion pattern 247590001 short-term memory within normal limits (finding)        
Assertion pattern 247592009 poor short-term memory (finding)        
ASSERTION PATTERN            
Assertion pattern 247587007 long-term memory within normal limits (finding)        
Assertion pattern 247588002 poor long-term memory (finding)        
Assertion pattern 165284008 memory: present time known (finding)        
Assertion pattern 165287001 memory: present place known (finding)        
Assertion pattern 285227006 able to remember faces (finding)        
Assertion pattern 165287001 memory: present place known (finding)        
QUESTION/ANSWER PATTERN 413383002 ability to make decisions (observable entity)        
Question/Answer pattern 304650003 able to use decision making strategies (finding)        
Question/Answer pattern 304652006 difficulty using decision making strategies (finding)        
Question/Answer pattern 304652006 difficulty using decision making strategies (finding)        
Question/Answer pattern 304651004 unable to use decision making strategies (finding)        
QUESTION/ANSWER PATTERN 52963003 attentiveness (observable entity)        
Question/Answer pattern 288773008 difficulty directing attention (finding)        
Question/Answer pattern 247767009 integrated attention for short spells (finding)        
QUESTION/ANSWER PATTERN 88952004 thinking, function (observable entity)        
Question/Answer pattern 247640008 unable to think clearly (finding)        
Question/Answer pattern 88962006 incomplete clear mindedness (finding)        
QUESTION/ANSWER PATTERN 6942003 level of consciousness (observable entity)        
Question/Answer pattern 3006004 disturbance of consciousness (finding)        
Question/Answer pattern 3006004 disturbance of consciousness (finding)        
QUESTION/ANSWER PATTERN 48761009 motor behavior (observable entity)        
Question/Answer pattern 398991009 motor retardation (finding)        
Question/Answer pattern 398991009 motor retardation (finding)        
ASSERTION PATTERN            
Assertion pattern 419284004 altered mental status (finding)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
D            
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
E            
Assertion pattern 7011001 hallucinations (finding)        
Assertion pattern 2073000 delusions (finding)        
ASSERTION PATTERN            
Assertion pattern 225480004 physically abusive behavior (finding)        
Assertion pattern 225480004 physically abusive behavior (finding)        
Assertion pattern 225480004 physically abusive behavior (finding)        
ASSERTION PATTERN            
Assertion pattern 225478005 verbally abusive behavior (finding)        
Assertion pattern 225478005 verbally abusive behavior (finding)        
Assertion pattern 225478005 verbally abusive behavior (finding)        
ASSERTION PATTERN            
  Concept Not Mapped (Reason #4)– Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD.          
  Concept Not Mapped (Reason #4)– Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD.          
  Concept Not Mapped (Reason #4)– Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD.          
ASSERTION PATTERN            
Assertion pattern 81763001 at risk for injury (finding)        
ASSERTION PATTERN            
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
ASSERTION PATTERN            
Assertion pattern 88598008 impaired social interaction (finding)        
ASSERTION PATTERN            
Assertion pattern 391155006 at risk of harming others (finding)        
ASSERTION PATTERN            
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
ASSERTION PATTERN            
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
QUESTION/ANSWER PATTERN 405078008 compliance behavior (observable entity)        
Question/Answer pattern 105480006 refusal of treatment by patient (situation)        
Question/Answer pattern 105480006 refusal of treatment by patient (situation)        
Question/Answer pattern 105480006 refusal of treatment by patient (situation)        
QUESTION/ANSWER PATTERN 363896009 behavior observable (observable entity)        
Question/Answer pattern 50239007 wandering (finding)        
Question/Answer pattern 50239007 wandering (finding)        
Question/Answer pattern 50239007 wandering (finding)        
QUESTION/ANSWER PATTERN 315244000 change in behavior (observable entity)        
Question/Answer pattern 385425000 improved (qualifier value)        
Question/Answer pattern 231877006 worse (qualifier value)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
F            
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
G            
QUESTION/ANSWER PATTERN 301680009 ability to move in bed (observable entity)        
Question/Answer pattern 371153006 independently able (qualifier value)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 255469002 limited (qualifier value)        
Question/Answer pattern 41118005 extensive (qualifier value)        
Question/Answer pattern 371156003 does not, dependent (qualifier value)        
Question/Answer pattern 301684000 does not move in bed (finding)        
Question/Answer pattern 301684000 does not move in bed (finding)        
QUESTION/ANSWER PATTERN 165236004 chair/bed transfer ability (observable entity)        
Question/Answer pattern 371153006 independently able (qualifier value)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 255469002 limited (qualifier value)        
Question/Answer pattern 41118005 extensive (qualifier value)        
Question/Answer pattern 371156003 does not, dependent (qualifier value)        
Question/Answer pattern 302266005 does not transfer (finding)        
Question/Answer pattern 302266005 does not transfer (finding)        
QUESTION/ANSWER PATTERN 129006008 walking (observable entity)        
Question/Answer pattern 371153006 independently able (qualifier value)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 255469002 limited (qualifier value)        
Question/Answer pattern 41118005 extensive (qualifier value)        
Question/Answer pattern 371156003 does not, dependent (qualifier value)        
Question/Answer pattern 282147000 does not walk (finding)        
Question/Answer pattern 282147000 does not walk (finding)        
QUESTION/ANSWER PATTERN 418305009 self-propelled locomotion activity (observable entity)        
Question/Answer pattern 371153006 independently able (qualifier value)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 255469002 limited (qualifier value)        
Question/Answer pattern 41118005 extensive (qualifier value)        
Question/Answer pattern 371156003 does not, dependent (qualifier value)        
Question/Answer pattern 302045007 does not mobilize (finding)        
Question/Answer pattern 302045007 does not mobilize (finding)        
QUESTION/ANSWER PATTERN 48263008 eating (observable entity)        
Question/Answer pattern 371153006 independently able (qualifier value)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 255469002 limited (qualifier value)        
Question/Answer pattern 41118005 extensive (qualifier value)        
Question/Answer pattern 371156003 does not, dependent (qualifier value)        
Question/Answer pattern 289003008 does not feed self (finding)        
Question/Answer pattern 289003008 does not feed self (finding)        
QUESTION/ANSWER PATTERN 129004006 toileting (observable entity)        
Question/Answer pattern 371153006 independently able (qualifier value)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 255469002 limited (qualifier value)        
Question/Answer pattern 41118005 extensive (qualifier value)        
Question/Answer pattern 371156003 does not, dependent (qualifier value)        
Question/Answer pattern 284903008 does not perform toileting activities (finding)        
Question/Answer pattern 284903008 does not perform toileting activities (finding)        
QUESTION/ANSWER PATTERN 286850002 personal hygiene activities, function (observable entity)        
Question/Answer pattern 371153006 independently able (qualifier value)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 255469002 limited (qualifier value)        
Question/Answer pattern 41118005 extensive (qualifier value)        
Question/Answer pattern 371156003 does not, dependent (qualifier value)        
Question/Answer pattern 284783002 does not perform personal hygiene activity (finding)        
Question/Answer pattern 284783002 does not perform personal hygiene activity (finding)        
QUESTION/ANSWER PATTERN 364564000 range of joint movement (observable entity)        
Question/Answer pattern 70733008 limitation of joint movement (finding)        
Question/Answer pattern 70733008 limitation of joint movement (finding)        
QUESTION/ANSWER PATTERN 364564000 range of joint movement (observable entity)        
Question/Answer pattern 70733008 limitation of joint movement (finding)        
Question/Answer pattern 70733008 limitation of joint movement (finding)        
Assertion pattern 365112008 finding of walking aid use (finding)        
Assertion pattern 365112008 finding of walking aid use (finding)        
Assertion pattern 301578005 does mobilize using wheelchair (finding)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
H            
Assertion pattern 266765001 indwelling catheter inserted (situation)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Assertion pattern 385712009 ostomy care (regime/therapy)        
Assertion pattern 225103006 intermittent urethral catheterization (procedure)        
ASSERTION PATTERN            
Assertion pattern 37799002 urinary bladder training (regime/therapy)        
QUESTION/ANSWER PATTERN 249282008 frequency of incontinence (observable entity)        
Question/Answer pattern 260413007 none (qualifier value)        
Question/Answer pattern 84638005 occasional (qualifier value)        
Question/Answer pattern 70232002 frequent (qualifier value)        
Question/Answer pattern 255619001 total (qualifier value)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
QUESTION/ANSWER PATTERN 406217005 bowel continence status (observable entity)        
Question/Answer pattern 260413007 bowels: fully continent (finding)        
Question/Answer pattern 165230005 bowels: occasional accident (finding)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 72042002 incontinence of feces (finding)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
ASSERTION PATTERN            
Assertion pattern 385976008 bowel training (regime/therapy)        
ASSERTION PATTERN            
Assertion pattern 14760008 constipation (disorder)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
I            
Assertion pattern 363346000 malignant neoplastic disease (disorder) 199.1 C80.0    
Assertion pattern 271737000 anemia (disorder) 285.9 D64.9    
Assertion pattern 44808001 conduction disorder of the heart (disorder) 427.9 I49.9    
Assertion pattern 56265001 heart disease (disorder) 414.9 I25.10    
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping   Concept Not Mapped - Venous embolism/thrombosis (e.g. DVT) and pulmonary embolus do not have a common representation Concept Not Mapped - Venous embolism/thrombosis (e.g. DVT) and pulmonary embolus do not have a common representation    
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping   428.9 I50.9    
Assertion pattern 38341003 hypertensive disorder, systemic arterial (disorder) 401.9 I10    
Assertion pattern 28651003 orthostatic hypotension (disorder) 458.0 I95.1    
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping   443.9 I73.9    
Assertion pattern 19943007 cirrhosis of liver (disorder) 571.5 K74.60    
Assertion pattern 119291004 disorder of upper gastrointestinal tract (disorder) Concept Not Mapped - Disorders of the esophagus (e.g. GERD) and ulcers of the upper GI tract do not have a common representation Concept Not Mapped - Disorders of the esophagus (e.g. GERD) and ulcers of the upper GI tract do not have a common representation    
Assertion pattern 24526004 inflammatory bowel disease (disorder) Concept Not Mapped - Regional enteritis (e.g. Crohn's), ulcerative colitis and unspecified colitis do not have a common representation Concept Not Mapped - Regional enteritis (e.g. Crohn's), ulcerative colitis and unspecified colitis do not have a common representation    
Assertion pattern 266569009 benign prostatic hyperplasia (disorder) 600.00 N40.0    
Assertion pattern 42399005 renal failure syndrome (disorder) 593.9 N28.9    
Assertion pattern 398064005 neurogenic bladder (finding) 596.54 N31.9    
Assertion pattern 7163005 urinary tract obstruction (disorder) 599.60 N13.9    
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping   V09.91 Z16    
Assertion pattern 233604007 pneumonia (disorder) 486 J18.9    
Assertion pattern 105592009 septicemia (disorder) 038.9 A41.9    
Assertion pattern 56717001 tuberculosis (disorder) 011.90 A15.9    
Assertion pattern 68566005 urinary tract infectious disease (disorder) 599.0 N39.0    
Assertion pattern 3738000 viral hepatitis (disorder) 070.9 B19.9    
  Concept Not Mapped (Reason #5) - Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT   Concept Not Mapped - Open wounds of upper limbs, lower limbs, and other body sites do not have a common representation Concept Not Mapped - Open wounds of upper limbs, lower limbs, and other body sites do not have a common representation    
Assertion pattern 73211009 diabetes mellitus (disorder) 250.00 E11.9    
Assertion pattern 89627008 hyponatremia (disorder) 276.1 E87.1    
Assertion pattern 14140009 hyperkalemia (disorder) 276.8 E87.6    
Assertion pattern 55822004 hyperlipidemia (disorder) 272.4 E78.5    
Assertion pattern 14304000 disorder of thyroid gland (disorder) 246.9 E07.9    
Assertion pattern 399269003 arthropathy (disorder) 716.90 M19.90    
Assertion pattern 64859006 osteoporosis (disorder) 733.00 M81.0    
Assertion pattern 263225007 fracture of proximal end of femur (disorder) 820.9 S72.00    
  Concept Not Mapped (Reason #5) - Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT   Concept Not Mapped - Fractures of any site (excluding hip) do not have a common representation Concept Not Mapped - Fractures of any site (excluding hip) do not have a common representation    
Assertion pattern 26929004 Alzheimer's disease (disorder) 331.0 G30.9, with additional code to identify delirium, (if applicable) F05, F02.81, F02.80    
Assertion pattern 87486003 aphasia (finding) 784.3 R47.01    
Assertion pattern 128188000 cerebral palsy (disorder) 343.9 G80.9    
Assertion pattern 62914000 cerebrovascular disease (disorder) Concept Not Mapped - CVA and TIA do not have a common representation Concept Not Mapped - CVA and TIA do not have a common representation    
Assertion pattern 52448006 dementia (disorder) 294.8 F03    
Assertion pattern 23853001 disorder of the central nervous system (disorder) 342.90 G81.90    
Assertion pattern 60389000 paraplegia (disorder) 344.1 G82.30    
Assertion pattern 11538006 quadriplegia (disorder) 344.09 G82.50    
Assertion pattern 24700007 multiple sclerosis (disorder) 340 G35    
Assertion pattern 58756001 Huntington's chorea (disorder) 333.4 G10    
Assertion pattern 49049000 Parkinson's disease (disorder) 332.0 G20    
Assertion pattern 5158005 Gilles de la Tourette's syndrome (disorder) 307.23 F95.2    
Assertion pattern 128613002 seizure disorder (disorder) 345.90 G40.909    
Assertion pattern 127295002 traumatic brain injury (disorder) 854.00 Concept Not Mapped - Traumatic Brain Injury requires further specification - code for head injury NOS is S09.90x    
Assertion pattern 2492009 nutritional disorder (disorder) 263.9 E46    
Assertion pattern 197480006 anxiety disorder (disorder) 300.00 F41.9    
Assertion pattern 35489007 depressive disorder (disorder) 311 F32.9    
Assertion pattern 13746004 bipolar disorder (disorder) 296.80 F31.9    
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping   298.9 F29    
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping   295.90 F20.9    
Assertion pattern 47505003 posttraumatic stress disorder (disorder) 309.81 F43.10    
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping   Concept Not Mapped - Asthma and Chronic lung Disease/COPD do not have a common representation Concept Not Mapped - Asthma and Chronic lung Disease/COPD do not have a common representation    
Assertion pattern 409622000 respiratory failure (disorder) 518.81 J96.90    
Assertion pattern 371405004 disorder of eye proper (disorder) Concept Not Mapped - Cataracts, glaucoma and macular degeneration do not have a common representation Concept Not Mapped - Cataracts, glaucoma and macular degeneration do not have a common representation    
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
  Concept Not Mapped (Reason #6) – Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping          
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
J            
ASSERTION PATTERN            
Assertion pattern 410240006 pain control management (procedure)        
QUESTION/ANSWER PATTERN 364631005 pattern of pain (observable entity)        
Question/Answer pattern 255238004 continuous (qualifier value)        
Question/Answer pattern 70232002 frequent (qualifier value)        
Question/Answer pattern 84638005 occasional (qualifier value)        
Question/Answer pattern 89292003 rare (qualifier value)        
  225908003 pain score (observable entity)        
QUESTION/ANSWER PATTERN 406127006 pain intensity (observable entity)        
Question/Answer pattern 40196000 mild pain (finding)        
Question/Answer pattern 50415004 moderate pain (finding)        
Question/Answer pattern 76948002 severe pain (finding)        
Question/Answer pattern 301383001 horrible present pain (finding)        
Assertion pattern 60845006 dyspnea on exertion (finding)        
Assertion pattern 161941007 dyspnea at rest (finding)        
Assertion pattern 62744007 orthopnea (finding)        
ASSERTION PATTERN            
Assertion pattern 110483000 tobacco user (finding)        
ASSERTION PATTERN            
Assertion pattern 170969009 prognosis bad (finding)        
ASSERTION PATTERN            
Assertion pattern 428942009 history of fall (situation)        
ASSERTION PATTERN            
Assertion pattern 428942009 history of fall (situation)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
             
ASSERTION PATTERN            
Assertion pattern 161898004 falls (finding)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
             
             
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
             
             
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
K            
Assertion pattern 288904007 does not retain food in mouth (finding)        
Assertion pattern 288903001 does retain food in mouth (finding)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  50373000 body height measure (observable entity)        
  27113001 body weight (observable entity)        
QUESTION/ANSWER PATTERN 363806002 weight loss (amount) (observable entity)        
Question/Answer pattern 416528001 intentional weight loss (finding)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Assertion pattern 25156005 intravenous feeding of patient (regime/therapy)        
Assertion pattern 61420007 tube feeding of patient (regime/therapy)        
Assertion pattern 226207007 modified texture diet (finding)        
Assertion pattern 226077000 therapeutic diets (finding)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
L            
Assertion pattern 278542003 dental appliance or restoration finding (finding)        
Assertion pattern 278650002 edentulous (finding)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
M            
ASSERTION PATTERN            
Assertion pattern 285304000 at risk of pressure sore (finding)        
ASSERTION PATTERN            
Assertion pattern 421076008 pressure ulcer stage 1 (disorder)        
  264892003 number of pressure sores (observable entity)        
  264892003 number of pressure sores (observable entity)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  298059007 date of onset (observable entity)        
  264892003 number of pressure sores (observable entity)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  264892003 number of pressure sores (observable entity)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  264892003 number of pressure sores (observable entity)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  264892003 number of pressure sores (observable entity)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  264892003 number of pressure sores (observable entity)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
  401238003 length of wound (observable entity)        
  401239006 width of wound (observable entity)        
  425094009 depth of wound (observable entity)        
  271618001 impaired wound healing (finding)        
  271618001 impaired wound healing (finding)        
  271618001 impaired wound healing (finding)        
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
Assertion pattern 299990002 infection of foot (disorder)        
Assertion pattern 371087003 diabetic foot ulcer (disorder)        
  Concept Not Mapped (Reason #5) - Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT          
Assertion pattern 95324001 skin lesion (disorder)        
Assertion pattern 419635000 surgical wound finding (finding)        
Assertion pattern 125666000 burn (disorder)        
Assertion pattern 228617000 provision of pressure relief equipment (procedure)        
Assertion pattern 228617000 provision of pressure relief equipment (procedure)        
Assertion pattern 308739004 repositioning (procedure)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Assertion pattern 440461005 Skin ulcer care (regime/therapy)        
Assertion pattern 226007004 post-surgical wound care (regime/therapy)        
Assertion pattern 3895009 application of dressing (procedure)        
Assertion pattern 431695009 administration of drug or medicament to skin via topical route (procedure)        
Assertion pattern 3895009 application of dressing (procedure)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
N            
  Concept Not Mapped (Reason #3)– Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.          
Assertion Pattern 408490001 antipsychotic drug therapy (procedure)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Assertion Pattern 182764009 anticoagulant therapy (procedure)        
Assertion Pattern 281789004 antibiotic therapy (procedure)        
Assertion Pattern 395011005 prophylactic diuretic therapy (procedure)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
O            
Assertion Pattern 367336001 chemotherapy (procedure)        
Assertion Pattern 108290001 radiation oncology AND/OR radiotherapy (procedure)        
Assertion Pattern 57485005 oxygen therapy (procedure)        
Assertion Pattern 58058006 suction of patient (procedure)        
Assertion Pattern 385858000 tracheostomy care (regime/therapy)        
Assertion Pattern 409025002 ventilator care (regime/therapy)        
Assertion Pattern 243141005 mechanically assisted spontaneous ventilation (procedure)        
Assertion Pattern 386358000 administration of drug or medicament via intravenous route (procedure)        
Assertion Pattern 116859006 transfusion of blood product (procedure)        
Assertion Pattern 108241001 dialysis procedure (procedure)        
Assertion Pattern 385763009 hospice care (regime/therapy)        
Assertion Pattern 105386004 respite care of patient (regime/therapy)        
Assertion Pattern 275823006 isolation nursing (procedure)        
ASSERTION PATTERN            
  Concept Not Mapped (Reason #4)– Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD         Concept Not Mapped - No comparable CVX concept is available.
Assertion pattern 86198006 influenza vaccination (procedure)       141
  439272007 date of procedure (observable entity)        
QUESTION/ANSWER PATTERN 445032002 reason procedure not performed (observable entity)       Concept Not Mapped - No comparable CVX concept is available.
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 308532005 influenza vaccination status (finding)        
Question/Answer pattern 390796006 influenza vaccination contraindicated (situation)        
Question/Answer pattern 315640000 influenza vaccination declined (situation)        
Question/Answer pattern 171262002 immunization not offered (finding)        
Question/Answer pattern 182850000 drugs not issued (finding)        
ASSERTION PATTERN           Concept Not Mapped - No comparable CVX concept is available.
Assertion pattern 171259000 not up-to-date with immunizations (finding)        
Assertion pattern 171258008 up-to-date with immunizations (finding)        
QUESTION/ANSWER PATTERN 445032002 reason procedure not performed (observable entity)       Concept Not Mapped - No comparable CVX concept is available.
Question/Answer pattern 390795005 pneumococcal vaccination contraindicated (situation)        
Question/Answer pattern 401086001 pneumococcal vaccination declined (situation)        
Question/Answer pattern 171262002 immunization not offered (finding)        
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
P            
ASSERTION PATTERN            
Assertion pattern 64373007 placing bedrails (procedure)        
Assertion pattern 64373007 placing bedrails (procedure)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
             
             
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
             
             
  Concept Not Mapped (Reason #5) - Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT          
             
             
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
             
             
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
             
             
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
             
             
  Concept Not Mapped (Reason #5) - Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT          
             
             
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
Q            
QUESTION/ANSWER PATTERN 404984000 readiness for discharge to independent living (observable entity)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Question/Answer pattern 306689006 discharge home (procedure)        
  Concept Not Mapped (Reason #2)- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping          
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
T            
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
V            
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
X            
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
Z            
  Concept Not Mapped (Reason #1) – This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians          
Mapping Based on the Following Pattern for Representation of Data Element SNOMED CT Code SNOMED CT Fully Specified Name ICD-9-CM Code - Section/Only ICD-10-CM Code -- Section/ Only CDC Race & Ethnicity Codes* Codes for Vaccines Administered (CVX) -- Section O Only
OTHER            

 

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"StratEng-E.pdf" (pdf, 3.66Mb)

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"StratEng-F.pdf" (pdf, 162.5Kb)

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"StratEng-G.pdf" (pdf, 340.24Kb)

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"StratEng-H.pdf" (pdf, 173.91Kb)

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"StratEng-I.pdf" (pdf, 194.52Kb)

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"StratEng-J.pdf" (pdf, 311.03Kb)

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"StratEng-K.pdf" (pdf, 4Mb)

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"StratEng-L.pdf" (pdf, 2.33Mb)

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"StratEng-M.pdf" (pdf, 164.3Kb)

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