Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. MDS3.0 Items Mapping -- Model Of Use

12/01/2011

Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
A     Identification Information              
  A0100A   Facility National Provider Identifier (NPI) See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0100B   Facility CMS Certification Number (CCN) See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0100C   State provider number See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0200   Type of provider   Typical pattern CD   54582-2   1.3.6.1.4.1.12009.10.1.61
  A0200 1 Nursing home (SNF/NF)   Typical pattern CD   54582-2 LA10882-1 1.3.6.1.4.1.12009.10.1.61
  A0200 2 Swing bed   Typical pattern CD   54582-2 LA10883-9 1.3.6.1.4.1.12009.10.1.61
  A0310A   Type of assessment: OBRA   Typical pattern CD   54583-0   1.3.6.1.4.1.12009.10.1.60
  A0310A 1 Admission assessment (required by day 14)   Typical pattern CD   54583-0 LA10-4 1.3.6.1.4.1.12009.10.1.60
  A0310A 2 Quarterly review assessment   Typical pattern CD   54583-0 LA15-3 1.3.6.1.4.1.12009.10.1.60
  A0310A 3 Annual assessment   Typical pattern CD   54583-0 LA12-0 1.3.6.1.4.1.12009.10.1.60
  A0310A 4 Significant change in status assessment   Typical pattern CD   54583-0 LA13-8 1.3.6.1.4.1.12009.10.1.60
  A0310A 5 Significant correction to prior comprehensive assessment   Typical pattern CD   54583-0 LA10888-8 1.3.6.1.4.1.12009.10.1.60
  A0310A 6 Significant correction to prior quarterly assessment   Typical pattern CD   54583-0 LA10889-6 1.3.6.1.4.1.12009.10.1.60
  A0310A 99 Not OBRA required assessment/tracking   Typical pattern CD   54583-0 LA10893-8 1.3.6.1.4.1.12009.10.1.60
  A0310B   Type of assessment: PPS   Typical pattern CD   54584-8   1.3.6.1.4.1.12009.10.1.59
  A0310B 1 5-day scheduled assessment   Typical pattern CD   54584-8 LA10894-6 1.3.6.1.4.1.12009.10.1.59
  A0310B 2 14-day scheduled assessment   Typical pattern CD   54584-8 LA10895-3 1.3.6.1.4.1.12009.10.1.59
  A0310B 3 30-day scheduled assessment   Typical pattern CD   54584-8 LA10896-1 1.3.6.1.4.1.12009.10.1.59
  A0310B 4 60-day scheduled assessment   Typical pattern CD   54584-8 LA10897-9 1.3.6.1.4.1.12009.10.1.59
  A0310B 5 90-day scheduled assessment   Typical pattern CD   54584-8 LA10898-7 1.3.6.1.4.1.12009.10.1.59
  A0310B 6 Readmission/return assessment   Typical pattern CD   54584-8 LA10899-5 1.3.6.1.4.1.12009.10.1.59
  A0310B 7 Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)   Typical pattern CD   54584-8 LA10900-1 1.3.6.1.4.1.12009.10.1.59
  A0310B 99 Not a PPS assessment   Typical pattern CD   54584-8 LA10903-5 1.3.6.1.4.1.12009.10.1.59
  A0310C   Type of assessment: OMRA   Typical pattern CD   54585-5   1.3.6.1.4.1.12009.10.1.65
  A0310C 0 No   Typical pattern CD   54585-5 LA32-8 1.3.6.1.4.1.12009.10.1.65
  A0310C 1 Start of therapy assessment   Typical pattern CD   54585-5 LA12624-5 1.3.6.1.4.1.12009.10.1.65
  A0310C 2 End of therapy assessment   Typical pattern CD   54585-5 LA12625-2 1.3.6.1.4.1.12009.10.1.65
  A0310C 3 Both Start and End of therapy assessment   Typical pattern CD   54585-5 LA12626-0 1.3.6.1.4.1.12009.10.1.65
  A0310D   Swing bed clinical change assessment   Typical pattern CD   58107-4   1.3.6.1.4.1.12009.10.1.62
  A0310D 0 No   Typical pattern CD   58107-4 LA32-8 1.3.6.1.4.1.12009.10.1.62
  A0310D 1 Yes   Typical pattern CD   58107-4 LA33-6 1.3.6.1.4.1.12009.10.1.62
  A0310E   First assessment since most recent entry   Typical pattern CD   54587-1   1.3.6.1.4.1.12009.10.1.62
  A0310E 0 No   Typical pattern CD   54587-1 LA32-8 1.3.6.1.4.1.12009.10.1.62
  A0310E 1 Yes   Typical pattern CD   54587-1 LA33-6 1.3.6.1.4.1.12009.10.1.62
  A0310F   Entry/discharge reporting   Typical pattern CD   58108-2   1.3.6.1.4.1.12009.10.1.66
  A0310F 1 Entry record   Typical pattern CD   58108-2 LA12627-8 1.3.6.1.4.1.12009.10.1.66
  A0310F 10 Discharge assessment - return not anticipated   Typical pattern CD   58108-2 LA12628-6 1.3.6.1.4.1.12009.10.1.66
  A0310F 11 Discharge assessment - return anticipated   Typical pattern CD   58108-2 LA12629-4 1.3.6.1.4.1.12009.10.1.66
  A0310F 12 Death in facility record   Typical pattern CD   58108-2 LA12630-2 1.3.6.1.4.1.12009.10.1.66
  A0310F 99 Not entry/discharge record   Typical pattern CD   58108-2 LA12631-0 1.3.6.1.4.1.12009.10.1.66
  A0410   Submission requirement   Typical pattern CD   54896-6   1.3.6.1.4.1.12009.10.1.23
  A0410 1 Neither federal nor state required submission   Typical pattern CD   54896-6 LA10908-4 1.3.6.1.4.1.12009.10.1.23
  A0410 2 State but not federal required submission (FOR NURSING HOMES ONLY)   Typical pattern CD   54896-6 LA10907-6 1.3.6.1.4.1.12009.10.1.23
  A0410 3 Federal required submission   Typical pattern CD   54896-6 LA10906-8 1.3.6.1.4.1.12009.10.1.23
  A0500A   Resident first name See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0500B   Resident middle initial See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0500C   Resident last name See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0500D   Resident name suffix See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0600A   Social Security Number See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0600B   Resident Medicare/railroad insurance number See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0700   Resident Medicaid number See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0800   Gender See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0800 1 Male See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0800 2 Female See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A0900   Birthdate See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1000A   Ethnicity: American Indian or Alaska Native   Ethnicity pattern CD       2.16.840.1.113883.1.11.15836
  A1000B   Ethnicity: Asian   Ethnicity pattern CD       2.16.840.1.113883.1.11.15836
  A1000C   Ethnicity: Black or African American   Ethnicity pattern CD       2.16.840.1.113883.1.11.15836
  A1000D   Ethnicity: Hispanic or Latino   Ethnicity pattern CD       2.16.840.1.113883.1.11.15836
  A1000E   Ethnicity: Native Hawaiian/Pacific Islander   Ethnicity pattern CD       2.16.840.1.113883.1.11.15836
  A1000F   Ethnicity: White   Ethnicity pattern CD       2.16.840.1.113883.1.11.15836
  A1100A   Does the resident need or want an interpreter   Typical pattern CD   54588-9   1.3.6.1.4.1.12009.10.1.58
  A1100A 0 No   Typical pattern CD   54588-9 LA32-8 1.3.6.1.4.1.12009.10.1.58
  A1100A 1 Yes   Typical pattern CD   54588-9 LA33-6 1.3.6.1.4.1.12009.10.1.58
  A1100A 9 Unable to determine   Typical pattern CD   54588-9 LA11137-9 1.3.6.1.4.1.12009.10.1.58
  A1100B   Preferred language   Other response data type pattern ED   54899-0    
  A1200   Marital status See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1200 1 Never married See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1200 2 Married See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1200 3 Widowed See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1200 4 Separated See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1200 5 Divorced See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1300A MDCL_REC_NUM Medical record number See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1300B ROOM_NUM Room number See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1300C PREFRD_NAME Name by which resident prefers to be addressed See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1300D   Lifetime occupation(s)   Other response data type pattern ED   45418-1    
  A1500   Resident evaluated by PASRR   Typical pattern CD   54589-7   1.3.6.1.4.1.12009.10.1.57
  A1500 0 No   Typical pattern CD   54589-7 LA32-8 1.3.6.1.4.1.12009.10.1.57
  A1500 1 Yes   Typical pattern CD   54589-7 LA33-6 1.3.6.1.4.1.12009.10.1.57
  A1500 9 Not a Medicaid certified unit   Typical pattern CD   54589-7 LA10921-7 1.3.6.1.4.1.12009.10.1.57
  A1550A   MR/DD status: Down syndrome   Multiple response pattern BL   45422-3    
  A1550B   MR/DD status: Autism   Multiple response pattern BL   45423-1    
  A1550C   MR/DD status: Epilepsy   Multiple response pattern BL   45424-9    
  A1550D   MR/DD status: other organic MR/DD condition   Multiple response pattern BL    45425-6    
  A1550E   MR/DD status: MR/DD with no organic condition   Multiple response pattern BL   45426-4    
  A1550Z   MR/DD status: none of the above   Multiple response pattern BL   45421-5    
  A1600   Entry date (date of admission/reentry in facility) See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A1700   Type of entry   Typical pattern CD   54590-5   1.3.6.1.4.1.12009.10.1.56
  A1700 1 Admission   Typical pattern CD   54590-5 LA10922-5 1.3.6.1.4.1.12009.10.1.56
  A1700 2 Reentry   Typical pattern CD   54590-5 LA54-2 1.3.6.1.4.1.12009.10.1.56
  A1800   Entered from   Typical pattern CD   54591-3   1.3.6.1.4.1.12009.10.1.55
  A1800 1 Community (private home/apt., board/ care, assisted living, group home)   Typical pattern CD   54591-3 LA10924-1 1.3.6.1.4.1.12009.10.1.55
  A1800 2 Another nursing home or swing bed   Typical pattern CD   54591-3 LA10925-8 1.3.6.1.4.1.12009.10.1.55
  A1800 3 Acute hospital   Typical pattern CD   54591-3 LA9928-8 1.3.6.1.4.1.12009.10.1.55
  A1800 4 Psychiatric hospital   Typical pattern CD   54591-3 LA10064-6 1.3.6.1.4.1.12009.10.1.55
  A1800 5 Inpatient rehabilitation facility   Typical pattern CD   54591-3 LA10928-2 1.3.6.1.4.1.12009.10.1.55
  A1800 6 MR/DD facility   Typical pattern CD   54591-3 LA10929-0 1.3.6.1.4.1.12009.10.1.55
  A1800 7 Hospice   Typical pattern CD   54591-3 LA6216-1 1.3.6.1.4.1.12009.10.1.55
  A1800 99 Other   Typical pattern CD   54591-3 LA46-8 1.3.6.1.4.1.12009.10.1.55
  A2000   Discharge date See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100   Discharge status See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 1 Community (private home/apt., board/ care, assisted living, group home) See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 2 Another nursing home or swing bed See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 3 Acute hospital See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 4 Psychiatric hospital See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 5 Inpatient rehabilitation facility See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 6 MR/DD facility See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 7 Hospice See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 8 Deceased See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2100 99 Other See CDA X-Path Mapping
Table 6
Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
  A2200   Previous asmt reference date for signif correction   Other response data type pattern TS   54592-1    
  A2300   Assessment reference date   Other response data type pattern TS   54593-9    
  A2400A   Has resident had Medicare-covered stay   Typical pattern CD   54594-7   1.3.6.1.4.1.12009.10.1.62
  A2400A 0 No   Typical pattern CD   54594-7 LA32-8 1.3.6.1.4.1.12009.10.1.62
  A2400A 1 Yes   Typical pattern CD   54594-7 LA33-6 1.3.6.1.4.1.12009.10.1.62
  A2400B   Start date of most recent Medicare stay   Other response data type pattern TS   54595-4    
  A2400C   End date of most recent Medicare stay   Other response data type pattern TS   54596-2    
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
B     Hearing, Speech, and Vision              
  B0100   Comatose   Typical pattern CD   54597-0   1.3.6.1.4.1.12009.10.1.62
  B0100 0 No   Typical pattern CD   54597-0 LA32-8 1.3.6.1.4.1.12009.10.1.62
  B0100 1 Yes   Typical pattern CD   54597-0 LA33-6 1.3.6.1.4.1.12009.10.1.62
  B0200   Hearing   Typical pattern CD   54598-8   1.3.6.1.4.1.12009.10.1.53
  B0200 0 Adequate - no difficulty in normal conversation, social interaction, listening to TV   Typical pattern CD   54598-8 LA10941-5 1.3.6.1.4.1.12009.10.1.53
  B0200 1 Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)   Typical pattern CD   54598-8 LA10942-3 1.3.6.1.4.1.12009.10.1.53
  B0200 2 Moderate difficulty - speaker has to increase volume and speak distinctly   Typical pattern CD   54598-8 LA10943-1 1.3.6.1.4.1.12009.10.1.53
  B0200 3 Highly impaired - absence of useful hearing   Typical pattern CD   54598-8 LA10944-9 1.3.6.1.4.1.12009.10.1.53
  B0300   Hearing aid   Typical pattern CD   54599-6   1.3.6.1.4.1.12009.10.1.62
  B0300 0 No   Typical pattern CD   54599-6 LA32-8 1.3.6.1.4.1.12009.10.1.62
  B0300 1 Yes   Typical pattern CD   54599-6 LA33-6 1.3.6.1.4.1.12009.10.1.62
  B0600   Speech clarity   Typical pattern CD   54600-2   1.3.6.1.4.1.12009.10.1.52
  B0600 0 Clear speech - distinct intelligible words   Typical pattern CD   54600-2 LA10945-6 1.3.6.1.4.1.12009.10.1.52
  B0600 1 Unclear speech - slurred or mumbled words   Typical pattern CD   54600-2 LA10946-4 1.3.6.1.4.1.12009.10.1.52
  B0600 2 No speech - absence of spoken words   Typical pattern CD   54600-2 LA10947-2 1.3.6.1.4.1.12009.10.1.52
  B0700   Makes self understood   Typical pattern CD   54601-0   1.3.6.1.4.1.12009.10.1.51
  B0700 0 Understood   Typical pattern CD   54601-0 LA71-6 1.3.6.1.4.1.12009.10.1.51
  B0700 1 Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time   Typical pattern CD   54601-0 LA10949-8 1.3.6.1.4.1.12009.10.1.51
  B0700 2 Sometimes understood - ability is limited to making concrete requests   Typical pattern CD   54601-0 LA10950-6 1.3.6.1.4.1.12009.10.1.51
  B0700 3 Rarely/never understood   Typical pattern CD   54601-0 LA74-0 1.3.6.1.4.1.12009.10.1.51
  B0800   Ability to understand others   Typical pattern CD   54602-8   1.3.6.1.4.1.12009.10.1.50
  B0800 0 Understands - clear comprehension   Typical pattern CD   54602-8 LA10952-2 1.3.6.1.4.1.12009.10.1.50
  B0800 1 Usually understands - misses some part/intent of message but comprehends most conversation   Typical pattern CD   54602-8 LA10953-0 1.3.6.1.4.1.12009.10.1.50
  B0800 2 Sometimes understands - responds adequately to simple, direct communication only   Typical pattern CD   54602-8 LA10954-8 1.3.6.1.4.1.12009.10.1.50
  B0800 3 Rarely/never understands   Typical pattern CD   54602-8 LA81-5 1.3.6.1.4.1.12009.10.1.50
  B1000   Vision   Typical pattern CD   54603-6   1.3.6.1.4.1.12009.10.1.49
  B1000 0 Adequate - sees fine detail, including regular print in newspapers/books   Typical pattern CD   54603-6 LA10956-3 1.3.6.1.4.1.12009.10.1.49
  B1000 1 Impaired - sees large print, but not regular print in newspapers/books   Typical pattern CD   54603-6 LA10957-1 1.3.6.1.4.1.12009.10.1.49
  B1000 2 Moderately Impaired - limited vision; not able to see newspaper headlines but can identify objects   Typical pattern CD   54603-6 LA10958-9 1.3.6.1.4.1.12009.10.1.49
  B1000 3 Highly impaired - object identification in question, but eyes appear to follow objects   Typical pattern CD   54603-6 LA10959-7 1.3.6.1.4.1.12009.10.1.49
  B1000 4 Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects   Typical pattern CD   54603-6 LA10960-5 1.3.6.1.4.1.12009.10.1.49
  B1200   Corrective lenses   Typical pattern CD   54604-4   1.3.6.1.4.1.12009.10.1.62
  B1200 0 No   Typical pattern CD   54604-4 LA32-8 1.3.6.1.4.1.12009.10.1.62
  B1200 1 Yes   Typical pattern CD   54604-4 LA33-6 1.3.6.1.4.1.12009.10.1.62
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
C     Cognitive Patterns              
  C0100   BIMS: should resident interview be conducted   Typical pattern CD   54605-1   1.3.6.1.4.1.12009.10.1.2
  C0100 0 No (resident is rarely/never understood)   Typical pattern CD   54605-1 LA11150-2 1.3.6.1.4.1.12009.10.1.2
  C0100 1 Yes   Typical pattern CD   54605-1 LA33-6 1.3.6.1.4.1.12009.10.1.2
  C0200   BIMS res interview: repetition of three words   Typical pattern CD   52731-7   1.3.6.1.4.1.12009.10.1.6
  C0200 0 None   Typical pattern CD   52731-7 LA137-2 1.3.6.1.4.1.12009.10.1.6
  C0200 1 One   Typical pattern CD   52731-7 LA6306-0 1.3.6.1.4.1.12009.10.1.6
  C0200 2 Two   Typical pattern CD   52731-7 LA6404-3 1.3.6.1.4.1.12009.10.1.6
  C0200 3 Three   Typical pattern CD   52731-7 LA6395-3 1.3.6.1.4.1.12009.10.1.6
  C0300A   BIMS res interview: able to report correct year   Typical pattern CD   52732-5   1.3.6.1.4.1.12009.10.1.48
  C0300A 0 Missed by > 5 years or no answer   Typical pattern CD   52732-5 LA10965-4 1.3.6.1.4.1.12009.10.1.48
  C0300A 1 Missed by 2-5 years   Typical pattern CD   52732-5 LA10966-2 1.3.6.1.4.1.12009.10.1.48
  C0300A 2 Missed by 1 year   Typical pattern CD   52732-5 LA10008-3 1.3.6.1.4.1.12009.10.1.48
  C0300A 3 Correct   Typical pattern CD   52732-5 LA9960-1 1.3.6.1.4.1.12009.10.1.48
  C0300B   BIMS res interview: able to report correct month   Typical pattern CD   52733-3   1.3.6.1.4.1.12009.10.1.47
  C0300B 0 Missed by > 1 month or no answer   Typical pattern CD   52733-3 LA10969-6 1.3.6.1.4.1.12009.10.1.47
  C0300B 1 Missed by 6 days to 1 month   Typical pattern CD   52733-3 LA10010-9 1.3.6.1.4.1.12009.10.1.47
  C0300B 2 Accurate within 5 days   Typical pattern CD   52733-3 LA9927-0 1.3.6.1.4.1.12009.10.1.47
  C0300C   BIMS res interview: can report correct day of week   Typical pattern CD   54609-3   1.3.6.1.4.1.12009.10.1.46
  C0300C 0 Incorrect or no answer   Typical pattern CD   54609-3 LA9981-7 1.3.6.1.4.1.12009.10.1.46
  C0300C 1 Correct   Typical pattern CD   54609-3 LA9960-1 1.3.6.1.4.1.12009.10.1.46
  C0400A   BIMS res interview: able to recall “sock”   Typical pattern CD   52735-8   1.3.6.1.4.1.12009.10.1.45
  C0400A 0 No - could not recall   Typical pattern CD   52735-8 LA10974-6 1.3.6.1.4.1.12009.10.1.45
  C0400A 1 Yes, after cueing (“something to wear”)   Typical pattern CD   52735-8 LA10126-3 1.3.6.1.4.1.12009.10.1.45
  C0400A 2 Yes, no cue required   Typical pattern CD   52735-8 LA10134-7 1.3.6.1.4.1.12009.10.1.45
  C0400B   BIMS res interview: able to recall “blue”   Typical pattern CD   52736-6   1.3.6.1.4.1.12009.10.1.44
  C0400B 0 No - could not recall   Typical pattern CD   52736-6 LA10974-6 1.3.6.1.4.1.12009.10.1.44
  C0400B 1 Yes, after cueing (“a color”)   Typical pattern CD   52736-6 LA10978-7 1.3.6.1.4.1.12009.10.1.44
  C0400B 2 Yes, no cue required   Typical pattern CD   52736-6 LA10134-7 1.3.6.1.4.1.12009.10.1.44
  C0400C   BIMS res interview: able to recall “bed”   Typical pattern CD   52737-4   1.3.6.1.4.1.12009.10.1.43
  C0400C 0 No - could not recall   Typical pattern CD   52737-4 LA10974-6 1.3.6.1.4.1.12009.10.1.43
  C0400C 1 Yes, after cueing (“a piece of furniture”)   Typical pattern CD   52737-4 LA10125-5 1.3.6.1.4.1.12009.10.1.43
  C0400C 2 Yes, no cue required   Typical pattern CD   52737-4 LA10134-7 1.3.6.1.4.1.12009.10.1.43
  C0500   BIMS res interview: summary score   Other response data type pattern INT   54614-3    
  C0600   Staff asmt mental status: conduct asmt   Typical pattern CD   54615-0   1.3.6.1.4.1.12009.10.1.5
  C0600 0 No (resident was able to complete interview)   Typical pattern CD   54615-0 LA11145-2 1.3.6.1.4.1.12009.10.1.5
  C0600 1 Yes (resident was unable to complete interview)   Typical pattern CD   54615-0 LA11146-0 1.3.6.1.4.1.12009.10.1.5
  C0700   Staff asmt mental status: short-term memory OK   Typical pattern CD   54616-8   1.3.6.1.4.1.12009.10.1.42
  C0700 0 Memory OK   Typical pattern CD   54616-8 LA55-9 1.3.6.1.4.1.12009.10.1.42
  C0700 1 Memory problem   Typical pattern CD   54616-8 LA56-7 1.3.6.1.4.1.12009.10.1.42
  C0800   Staff asmt mental status: long-term memory OK   Typical pattern CD   54617-6   1.3.6.1.4.1.12009.10.1.42
  C0800 0 Memory OK   Typical pattern CD   54617-6 LA55-9 1.3.6.1.4.1.12009.10.1.42
  C0800 1 Memory problem   Typical pattern CD   54617-6 LA56-7 1.3.6.1.4.1.12009.10.1.42
  C0900A   Staff asmt mental status: recall current season   Multiple response pattern BL   54619-2    
  C0900B   Staff asmt mental status: recall location of room   Multiple response pattern BL   54620-0    
  C0900C   Staff asmt mental status: recall staff names/faces   Multiple response pattern BL   54621-8    
  C0900D   Staff asmt mental status: recall in nursing home   Multiple response pattern BL   54622-6    
  C0900Z   Staff asmt mental status: none of above recalled   Multiple response pattern BL   54623-4    
  C1000   Cognitive skills for daily decision making   Typical pattern CD   54624-2   1.3.6.1.4.1.12009.10.1.41
  C1000 0 Independent - decisions consistent/reasonable   Typical pattern CD   54624-2 LA10985-2 1.3.6.1.4.1.12009.10.1.41
  C1000 1 Modified independence - some difficulty in new situations only   Typical pattern CD   54624-2 LA10986-0 1.3.6.1.4.1.12009.10.1.41
  C1000 2 Moderately impaired - decisions poor; cues/supervision required   Typical pattern CD   54624-2 LA10987-8 1.3.6.1.4.1.12009.10.1.41
  C1000 3 Severely impaired - never/rarely made decisions   Typical pattern CD   54624-2 LA10988-6 1.3.6.1.4.1.12009.10.1.41
  C1300A   Signs of delirium: inattention   Typical pattern CD   54628-3   1.3.6.1.4.1.12009.10.1.39
  C1300A 0 Behavior not present   Typical pattern CD   54628-3 LA61-7 1.3.6.1.4.1.12009.10.1.39
  C1300A 1 Behavior continuously present, does not fluctuate   Typical pattern CD   54628-3 LA11143-7 1.3.6.1.4.1.12009.10.1.39
  C1300A 2 Behavior present, fluctuates (comes and goes, changes in severity)   Typical pattern CD   54628-3 LA10993-6 1.3.6.1.4.1.12009.10.1.39
  C1300B   Signs of delirium: disorganized thinking   Typical pattern CD   54629-1   1.3.6.1.4.1.12009.10.1.39
  C1300B 0 Behavior not present   Typical pattern CD   54629-1 LA61-7 1.3.6.1.4.1.12009.10.1.39
  C1300B 1 Behavior continuously present, does not fluctuate   Typical pattern CD   54629-1 LA11143-7 1.3.6.1.4.1.12009.10.1.39
  C1300B 2 Behavior present, fluctuates (comes and goes, changes in severity)   Typical pattern CD   54629-1 LA10993-6 1.3.6.1.4.1.12009.10.1.39
  C1300C   Signs of delirium: altered level of consciousness   Typical pattern CD   54630-9   1.3.6.1.4.1.12009.10.1.39
  C1300C 0 Behavior not present   Typical pattern CD   54630-9 LA61-7 1.3.6.1.4.1.12009.10.1.39
  C1300C 1 Behavior continuously present, does not fluctuate   Typical pattern CD   54630-9 LA11143-7 1.3.6.1.4.1.12009.10.1.39
  C1300C 2 Behavior present, fluctuates (comes and goes, changes in severity)   Typical pattern CD   54630-9 LA10993-6 1.3.6.1.4.1.12009.10.1.39
  C1300D   Signs of delirium: psychomotor retardation   Typical pattern CD   54631-7   1.3.6.1.4.1.12009.10.1.39
  C1300D 0 Behavior not present   Typical pattern CD   54631-7 LA61-7 1.3.6.1.4.1.12009.10.1.39
  C1300D 1 Behavior continuously present, does not fluctuate   Typical pattern CD   54631-7 LA11143-7 1.3.6.1.4.1.12009.10.1.39
  C1300D 2 Behavior present, fluctuates (comes and goes, changes in severity)   Typical pattern CD   54631-7 LA10993-6 1.3.6.1.4.1.12009.10.1.39
  C1600   Acute onset mental status change   Typical pattern CD   54632-5   1.3.6.1.4.1.12009.10.1.62
  C1600 0 No   Typical pattern CD   54632-5 LA32-8 1.3.6.1.4.1.12009.10.1.62
  C1600 1 Yes   Typical pattern CD   54632-5 LA33-6 1.3.6.1.4.1.12009.10.1.62
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
D     Mood              
  D0100   PHQ: should resident mood interview be conducted   Typical pattern CD   54634-1   1.3.6.1.4.1.12009.10.1.2
  D0100 0 No (resident is rarely/never understood)   Typical pattern CD   54634-1 LA11150-2 1.3.6.1.4.1.12009.10.1.2
  D0100 1 Yes   Typical pattern CD   54634-1 LA33-6 1.3.6.1.4.1.12009.10.1.2
  D0200A1   PHQ res: little interest or pleasure - presence   Typical pattern CD   54636-6   1.3.6.1.4.1.12009.10.1.38
  D0200A1 0 No (enter 0 in column 2)   Typical pattern CD   54636-6 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200A1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54636-6 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200A1 9 No response (leave column 2 blank)   Typical pattern CD   54636-6 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200A2   PHQ res: little interest or pleasure - frequency   Typical pattern CD   54637-4   1.3.6.1.4.1.12009.10.1.37
  D0200A2 0 Never or 1 day   Typical pattern CD   54637-4 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200A2 1 2-6 Days (Several days)   Typical pattern CD   54637-4 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200A2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54637-4 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200A2 3 12-14 Days (Nearly every day)   Typical pattern CD   54637-4 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200B1   PHQ res: feeling down, depressed - presence   Typical pattern CD   54638-2   1.3.6.1.4.1.12009.10.1.38
  D0200B1 0 No (enter 0 in column 2)   Typical pattern CD   54638-2 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200B1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54638-2 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200B1 9 No response (leave column 2 blank)   Typical pattern CD   54638-2 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200B2   PHQ res: feeling down, depressed - frequency   Typical pattern CD   54639-0   1.3.6.1.4.1.12009.10.1.37
  D0200B2 0 Never or 1 day   Typical pattern CD   54639-0 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200B2 1 2-6 Days (Several days)   Typical pattern CD   54639-0 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200B2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54639-0 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200B2 3 12-14 Days (Nearly every day)   Typical pattern CD   54639-0 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200C1   PHQ res: trouble with sleep - presence   Typical pattern CD   54640-8   1.3.6.1.4.1.12009.10.1.38
  D0200C1 0 No (enter 0 in column 2)   Typical pattern CD   54640-8 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200C1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54640-8 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200C1 9 No response (leave column 2 blank)   Typical pattern CD   54640-8 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200C2   PHQ res: trouble with sleep - frequency   Typical pattern CD   54641-6   1.3.6.1.4.1.12009.10.1.37
  D0200C2 0 Never or 1 day   Typical pattern CD   54641-6 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200C2 1 2-6 Days (Several days)   Typical pattern CD   54641-6 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200C2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54641-6 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200C2 3 12-14 Days (Nearly every day)   Typical pattern CD   54641-6 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200D1   PHQ res: feeling tired/little energy - presence   Typical pattern CD   54642-4   1.3.6.1.4.1.12009.10.1.38
  D0200D1 0 No (enter 0 in column 2)   Typical pattern CD   54642-4 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200D1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54642-4 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200D1 9 No response (leave column 2 blank)   Typical pattern CD   54642-4 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200D2   PHQ res: feeling tired/little energy - frequency   Typical pattern CD   54643-2   1.3.6.1.4.1.12009.10.1.37
  D0200D2 0 Never or 1 day   Typical pattern CD   54643-2 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200D2 1 2-6 Days (Several days)   Typical pattern CD   54643-2 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200D2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54643-2 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200D2 3 12-14 Days (Nearly every day)   Typical pattern CD   54643-2 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200E1   PHQ res: poor appetite or overeating - presence   Typical pattern CD   54644-0   1.3.6.1.4.1.12009.10.1.38
  D0200E1 0 No (enter 0 in column 2)   Typical pattern CD   54644-0 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200E1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54644-0 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200E1 9 No response (leave column 2 blank)   Typical pattern CD   54644-0 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200E2   PHQ res: poor appetite or overeating - frequency   Typical pattern CD   54645-7   1.3.6.1.4.1.12009.10.1.37
  D0200E2 0 Never or 1 day   Typical pattern CD   54645-7 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200E2 1 2-6 Days (Several days)   Typical pattern CD   54645-7 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200E2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54645-7 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200E2 3 12-14 Days (Nearly every day)   Typical pattern CD   54645-7 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200F1   PHQ res: feeling bad about self - presence   Typical pattern CD   54646-5   1.3.6.1.4.1.12009.10.1.38
  D0200F1 0 No (enter 0 in column 2)   Typical pattern CD   54646-5 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200F1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54646-5 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200F1 9 No response (leave column 2 blank)   Typical pattern CD   54646-5 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200F2   PHQ res: feeling bad about self - frequency   Typical pattern CD   54647-3   1.3.6.1.4.1.12009.10.1.37
  D0200F2 0 Never or 1 day   Typical pattern CD   54647-3 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200F2 1 2-6 Days (Several days)   Typical pattern CD   54647-3 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200F2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54647-3 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200F2 3 12-14 Days (Nearly every day)   Typical pattern CD   54647-3 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200G1   PHQ res: trouble concentrating - presence   Typical pattern CD   54648-1   1.3.6.1.4.1.12009.10.1.38
  D0200G1 0 No (enter 0 in column 2)   Typical pattern CD   54648-1 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200G1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54648-1 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200G1 9 No response (leave column 2 blank)   Typical pattern CD   54648-1 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200G2   PHQ res: trouble concentrating - frequency   Typical pattern CD   54649-9   1.3.6.1.4.1.12009.10.1.37
  D0200G2 0 Never or 1 day   Typical pattern CD   54649-9 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200G2 1 2-6 Days (Several days)   Typical pattern CD   54649-9 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200G2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54649-9 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200G2 3 12-14 Days (Nearly every day)   Typical pattern CD   54649-9 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200H1   PHQ res: slow, fidgety, restless - presence   Typical pattern CD   54650-7   1.3.6.1.4.1.12009.10.1.38
  D0200H1 0 No (enter 0 in column 2)   Typical pattern CD   54650-7 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200H1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54650-7 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200H1 9 No response (leave column 2 blank)   Typical pattern CD   54650-7 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200H2   PHQ res: slow, fidgety, restless - frequency   Typical pattern CD   54651-5   1.3.6.1.4.1.12009.10.1.37
  D0200H2 0 Never or 1 day   Typical pattern CD   54651-5 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200H2 1 2-6 Days (Several days)   Typical pattern CD   54651-5 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200H2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54651-5 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200H2 3 12-14 Days (Nearly every day)   Typical pattern CD   54651-5 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0200I1   PHQ res: thoughts better off dead - presence   Typical pattern CD   54652-3   1.3.6.1.4.1.12009.10.1.38
  D0200I1 0 No (enter 0 in column 2)   Typical pattern CD   54652-3 LA32-8 1.3.6.1.4.1.12009.10.1.38
  D0200I1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54652-3 LA33-6 1.3.6.1.4.1.12009.10.1.38
  D0200I1 9 No response (leave column 2 blank)   Typical pattern CD   54652-3 LA10996-9 1.3.6.1.4.1.12009.10.1.38
  D0200I2   PHQ res: thoughts better off dead - frequency   Typical pattern CD   54653-1   1.3.6.1.4.1.12009.10.1.37
  D0200I2 0 Never or 1 day   Typical pattern CD   54653-1 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0200I2 1 2-6 Days (Several days)   Typical pattern CD   54653-1 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0200I2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54653-1 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0200I2 3 12-14 Days (Nearly every day)   Typical pattern CD   54653-1 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0300   PHQ res: total mood severity score   Other response data type pattern INT   54654-9    
  D0350   PHQ res: safety notification   Typical pattern CD   54655-6   1.3.6.1.4.1.12009.10.1.62
  D0350 0 No   Typical pattern CD   54655-6 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0350 1 Yes   Typical pattern CD   54655-6 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500A1   PHQ staff: little interest or pleasure - presence   Typical pattern CD   54658-0   1.3.6.1.4.1.12009.10.1.62
  D0500A1 0 No (enter 0 in column 2)   Typical pattern CD   54658-0 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500A1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54658-0 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500A2   PHQ staff: little interest or pleasure - frequency   Typical pattern CD   54659-8   1.3.6.1.4.1.12009.10.1.37
  D0500A2 0 Never or 1 day   Typical pattern CD   54659-8 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500A2 1 2-6 Days (Several days)   Typical pattern CD   54659-8 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500A2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54659-8 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500A2 3 12-14 Days (Nearly every day)   Typical pattern CD   54659-8 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500B1   PHQ staff: feeling down, depressed - presence   Typical pattern CD   54660-6   1.3.6.1.4.1.12009.10.1.62
  D0500B1 0 No (enter 0 in column 2)   Typical pattern CD   54660-6 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500B1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54660-6 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500B2   PHQ staff: feeling down, depressed - frequency   Typical pattern CD   54661-4   1.3.6.1.4.1.12009.10.1.37
  D0500B2 0 Never or 1 day   Typical pattern CD   54661-4 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500B2 1 2-6 Days (Several days)   Typical pattern CD   54661-4 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500B2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54661-4 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500B2 3 12-14 Days (Nearly every day)   Typical pattern CD   54661-4 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500C1   PHQ staff: trouble with sleep - presence   Typical pattern CD   54662-2   1.3.6.1.4.1.12009.10.1.62
  D0500C1 0 No (enter 0 in column 2)   Typical pattern CD   54662-2 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500C1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54662-2 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500C2   PHQ staff: trouble with sleep - frequency   Typical pattern CD   54663-0   1.3.6.1.4.1.12009.10.1.37
  D0500C2 0 Never or 1 day   Typical pattern CD   54663-0 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500C2 1 2-6 Days (Several days)   Typical pattern CD   54663-0 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500C2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54663-0 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500C2 3 12-14 Days (Nearly every day)   Typical pattern CD   54663-0 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500D1   PHQ staff: feeling tired/little energy - presence   Typical pattern CD   54664-8   1.3.6.1.4.1.12009.10.1.62
  D0500D1 0 No (enter 0 in column 2)   Typical pattern CD   54664-8 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500D1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54664-8 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500D2   PHQ staff: feeling tired/little energy - frequency   Typical pattern CD   54665-5   1.3.6.1.4.1.12009.10.1.37
  D0500D2 0 Never or 1 day   Typical pattern CD   54665-5 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500D2 1 2-6 Days (Several days)   Typical pattern CD   54665-5 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500D2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54665-5 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500D2 3 12-14 Days (Nearly every day)   Typical pattern CD   54665-5 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500E1   PHQ staff: poor appetite or overeating - presence   Typical pattern CD   54666-3   1.3.6.1.4.1.12009.10.1.62
  D0500E1 0 No (enter 0 in column 2)   Typical pattern CD   54666-3 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500E1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54666-3 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500E2   PHQ staff: poor appetite or overeating - frequency   Typical pattern CD   54667-1   1.3.6.1.4.1.12009.10.1.37
  D0500E2 0 Never or 1 day   Typical pattern CD   54667-1 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500E2 1 2-6 Days (Several days)   Typical pattern CD   54667-1 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500E2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54667-1 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500E2 3 12-14 Days (Nearly every day)   Typical pattern CD   54667-1 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500F1   PHQ staff: feeling bad about self - presence   Typical pattern CD   54668-9   1.3.6.1.4.1.12009.10.1.62
  D0500F1 0 No (enter 0 in column 2)   Typical pattern CD   54668-9 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500F1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54668-9 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500F2   PHQ staff: feeling bad about self - frequency   Typical pattern CD   54669-7   1.3.6.1.4.1.12009.10.1.37
  D0500F2 0 Never or 1 day   Typical pattern CD   54669-7 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500F2 1 2-6 Days (Several days)   Typical pattern CD   54669-7 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500F2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54669-7 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500F2 3 12-14 Days (Nearly every day)   Typical pattern CD   54669-7 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500G1   PHQ staff: trouble concentrating - presence   Typical pattern CD   54670-5   1.3.6.1.4.1.12009.10.1.62
  D0500G1 0 No (enter 0 in column 2)   Typical pattern CD   54670-5 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500G1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54670-5 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500G2   PHQ staff: trouble concentrating - frequency   Typical pattern CD   54671-3   1.3.6.1.4.1.12009.10.1.37
  D0500G2 0 Never or 1 day   Typical pattern CD   54671-3 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500G2 1 2-6 Days (Several days)   Typical pattern CD   54671-3 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500G2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54671-3 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500G2 3 12-14 Days (Nearly every day)   Typical pattern CD   54671-3 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500H1   PHQ staff: slow, fidgety, restless - presence   Typical pattern CD   54672-1   1.3.6.1.4.1.12009.10.1.62
  D0500H1 0 No (enter 0 in column 2)   Typical pattern CD   54672-1 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500H1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54672-1 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500H2   PHQ staff: slow, fidgety, restless - frequency   Typical pattern CD   54904-8   1.3.6.1.4.1.12009.10.1.37
  D0500H2 0 Never or 1 day   Typical pattern CD   54904-8 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500H2 1 2-6 Days (Several days)   Typical pattern CD   54904-8 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500H2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54904-8 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500H2 3 12-14 Days (Nearly every day)   Typical pattern CD   54904-8 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500I1   PHQ staff: thoughts better off dead - presence   Typical pattern CD   54673-9   1.3.6.1.4.1.12009.10.1.62
  D0500I1 0 No (enter 0 in column 2)   Typical pattern CD   54673-9 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500I1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54673-9 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500I2   PHQ staff: thoughts better off dead - frequency   Typical pattern CD   54674-7   1.3.6.1.4.1.12009.10.1.37
  D0500I2 0 Never or 1 day   Typical pattern CD   54674-7 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500I2 1 2-6 Days (Several days)   Typical pattern CD   54674-7 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500I2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54674-7 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500I2 3 12-14 Days (Nearly every day)   Typical pattern CD   54674-7 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0500J1   PHQ staff: short-tempered - presence   Typical pattern CD   54675-4   1.3.6.1.4.1.12009.10.1.62
  D0500J1 0 No (enter 0 in column 2)   Typical pattern CD   54675-4 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0500J1 1 Yes (enter 0-3 in column 2)   Typical pattern CD   54675-4 LA33-6 1.3.6.1.4.1.12009.10.1.62
  D0500J2   PHQ staff: short-tempered - frequency   Typical pattern CD   54676-2   1.3.6.1.4.1.12009.10.1.37
  D0500J2 0 Never or 1 day   Typical pattern CD   54676-2 LA10997-7 1.3.6.1.4.1.12009.10.1.37
  D0500J2 1 2-6 Days (Several days)   Typical pattern CD   54676-2 LA10998-5 1.3.6.1.4.1.12009.10.1.37
  D0500J2 2 7-11 Days (Half or more of the days)   Typical pattern CD   54676-2 LA10999-3 1.3.6.1.4.1.12009.10.1.37
  D0500J2 3 12-14 Days (Nearly every day)   Typical pattern CD   54676-2 LA11000-9 1.3.6.1.4.1.12009.10.1.37
  D0600   PHQ staff: total mood score   Other response data type pattern INT   54677-0    
  D0650   PHQ staff: safety notification   Typical pattern CD   54655-6   1.3.6.1.4.1.12009.10.1.62
  D0650 0 No   Typical pattern CD   54655-6 LA32-8 1.3.6.1.4.1.12009.10.1.62
  D0650 1 Yes   Typical pattern CD   54655-6 LA33-6 1.3.6.1.4.1.12009.10.1.62
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
E     Behavior              
  E0100A   Psychosis: hallucinations   Multiple response pattern BL   54678-8    
  E0100B   Psychosis: delusions     Multiple response pattern BL   54680-4    
  E0100Z   Psychosis: none of the above   Multiple response pattern BL   54681-2    
  E0200A   Physical behav symptoms directed toward others   Typical pattern CD   54682-0   1.3.6.1.4.1.12009.10.1.35
  E0200A 0 Behavior not exhibited   Typical pattern CD   54682-0 LA11005-8 1.3.6.1.4.1.12009.10.1.35
  E0200A 1 Behavior of this type occurred 1 to 3 days   Typical pattern CD   54682-0 LA11006-6 1.3.6.1.4.1.12009.10.1.35
  E0200A 2 Behavior of this type occurred 4 to 6 days, but less than daily   Typical pattern CD   54682-0 LA94-8 1.3.6.1.4.1.12009.10.1.35
  E0200A 3 Behavior of this type occurred daily   Typical pattern CD   54682-0 LA95-5 1.3.6.1.4.1.12009.10.1.35
  E0200B   Verbal behav symptoms directed toward others   Typical pattern CD   54683-8   1.3.6.1.4.1.12009.10.1.35
  E0200B 0 Behavior not exhibited   Typical pattern CD   54683-8 LA11005-8 1.3.6.1.4.1.12009.10.1.35
  E0200B 1 Behavior of this type occurred 1 to 3 days   Typical pattern CD   54683-8 LA11006-6 1.3.6.1.4.1.12009.10.1.35
  E0200B 2 Behavior of this type occurred 4 to 6 days, but less than daily   Typical pattern CD   54683-8 LA94-8 1.3.6.1.4.1.12009.10.1.35
  E0200B 3 Behavior of this type occurred daily   Typical pattern CD   54683-8 LA95-5 1.3.6.1.4.1.12009.10.1.35
  E0200C   Other behav symptoms not directed toward others   Typical pattern CD   54684-6   1.3.6.1.4.1.12009.10.1.35
  E0200C 0 Behavior not exhibited   Typical pattern CD   54684-6 LA11005-8 1.3.6.1.4.1.12009.10.1.35
  E0200C 1 Behavior of this type occurred 1 to 3 days   Typical pattern CD   54684-6 LA11006-6 1.3.6.1.4.1.12009.10.1.35
  E0200C 2 Behavior of this type occurred 4 to 6 days, but less than daily   Typical pattern CD   54684-6 LA94-8 1.3.6.1.4.1.12009.10.1.35
  E0200C 3 Behavior of this type occurred daily   Typical pattern CD   54684-6 LA95-5 1.3.6.1.4.1.12009.10.1.35
  E0300   Overall presence of behavioral symptoms   Typical pattern CD   54685-3   1.3.6.1.4.1.12009.10.1.62
  E0300 0 No   Typical pattern CD   54685-3 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E0300 1 Yes   Typical pattern CD   54685-3 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E0500A   Behav symptoms put res at risk for illness/injury   Typical pattern CD   54686-1   1.3.6.1.4.1.12009.10.1.62
  E0500A 0 No   Typical pattern CD   54686-1 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E0500A 1 Yes   Typical pattern CD   54686-1 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E0500B   Behav symptoms interfere with resident care   Typical pattern CD   54687-9   1.3.6.1.4.1.12009.10.1.62
  E0500B 0 No   Typical pattern CD   54687-9 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E0500B 1 Yes   Typical pattern CD   54687-9 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E0500C   Behav symptoms interfere with social activities   Typical pattern CD   54688-7   1.3.6.1.4.1.12009.10.1.62
  E0500C 0 No   Typical pattern CD   54688-7 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E0500C 1 Yes   Typical pattern CD   54688-7 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E0600A   Behav symptoms put others at risk for injury   Typical pattern CD   54689-5   1.3.6.1.4.1.12009.10.1.62
  E0600A 0 No   Typical pattern CD   54689-5 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E0600A 1 Yes   Typical pattern CD   54689-5 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E0600B   Behav symptoms intrude on privacy of others   Typical pattern CD   54690-3   1.3.6.1.4.1.12009.10.1.62
  E0600B 0 No   Typical pattern CD   54690-3 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E0600B 1 Yes   Typical pattern CD   54690-3 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E0600C   Behav symptoms disrupt care or living environment   Typical pattern CD   54691-1   1.3.6.1.4.1.12009.10.1.62
  E0600C 0 No   Typical pattern CD   54691-1 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E0600C 1 Yes   Typical pattern CD   54691-1 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E0800   Rejection of care: presence and frequency   Typical pattern CD   54692-9   1.3.6.1.4.1.12009.10.1.35
  E0800 0 Behavior not exhibited   Typical pattern CD   54692-9 LA11005-8 1.3.6.1.4.1.12009.10.1.35
  E0800 1 Behavior of this type occurred 1 to 3 days   Typical pattern CD   54692-9 LA11006-6 1.3.6.1.4.1.12009.10.1.35
  E0800 2 Behavior of this type occurred 4 to 6 days, but less than daily   Typical pattern CD   54692-9 LA94-8 1.3.6.1.4.1.12009.10.1.35
  E0800 3 Behavior of this type occurred daily   Typical pattern CD   54692-9 LA95-5 1.3.6.1.4.1.12009.10.1.35
  E0900   Wandering: presence and frequency   Typical pattern CD   54693-7   1.3.6.1.4.1.12009.10.1.35
  E0900 0 Behavior not exhibited   Typical pattern CD   54693-7 LA11005-8 1.3.6.1.4.1.12009.10.1.35
  E0900 1 Behavior of this type occurred 1 to 3 days   Typical pattern CD   54693-7 LA11006-6 1.3.6.1.4.1.12009.10.1.35
  E0900 2 Behavior of this type occurred 4 to 6 days, but less than daily   Typical pattern CD   54693-7 LA94-8 1.3.6.1.4.1.12009.10.1.35
  E0900 3 Behavior of this type occurred daily   Typical pattern CD   54693-7 LA95-5 1.3.6.1.4.1.12009.10.1.35
  E1000A   Wandering: risk of getting to dangerous place   Typical pattern CD   54694-5   1.3.6.1.4.1.12009.10.1.62
  E1000A 0 No   Typical pattern CD   54694-5 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E1000A 1 Yes   Typical pattern CD   54694-5 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E1000B   Wandering: intrude on privacy of others   Typical pattern CD   54695-2   1.3.6.1.4.1.12009.10.1.62
  E1000B 0 No   Typical pattern CD   54695-2 LA32-8 1.3.6.1.4.1.12009.10.1.62
  E1000B 1 Yes   Typical pattern CD   54695-2 LA33-6 1.3.6.1.4.1.12009.10.1.62
  E1100   Change in behavioral or other symptoms   Typical pattern CD   54696-0   1.3.6.1.4.1.12009.10.1.34
  E1100 0 Same   Typical pattern CD   54696-0 LA11009-0 1.3.6.1.4.1.12009.10.1.34
  E1100 1 Improved   Typical pattern CD   54696-0 LA65-8 1.3.6.1.4.1.12009.10.1.34
  E1100 2 Worse   Typical pattern CD   54696-0 LA11011-6 1.3.6.1.4.1.12009.10.1.34
  E1100 9 N/A because no prior MDS assessment   Typical pattern CD   54696-0 LA11012-4 1.3.6.1.4.1.12009.10.1.34
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
F     Preferences for Customary Routine and Activities              
  F0300   Conduct res interview for daily/activity prefs   Typical pattern CD   54697-8   1.3.6.1.4.1.12009.10.1.3
  F0300 0 No (resident is rarely/never understood and family/ significant other not available)   Typical pattern CD   54697-8 LA11149-4 1.3.6.1.4.1.12009.10.1.3
  F0300 1 Yes   Typical pattern CD   54697-8 LA33-6 1.3.6.1.4.1.12009.10.1.3
  F0400A   Res interview: choose clothes to wear   Typical pattern CD   54698-6   1.3.6.1.4.1.12009.10.1.33
  F0400A 1 Very important   Typical pattern CD   54698-6 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400A 2 Somewhat important   Typical pattern CD   54698-6 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400A 3 Not very important   Typical pattern CD   54698-6 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400A 4 Not important at all   Typical pattern CD   54698-6 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400A 5 Important, but can't do or no choice   Typical pattern CD   54698-6 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400A 9 No response or non-responsive   Typical pattern CD   54698-6 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0400B   Res interview: take care of personal belongings   Typical pattern CD   54699-4   1.3.6.1.4.1.12009.10.1.33
  F0400B 1 Very important   Typical pattern CD   54699-4 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400B 2 Somewhat important   Typical pattern CD   54699-4 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400B 3 Not very important   Typical pattern CD   54699-4 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400B 4 Not important at all   Typical pattern CD   54699-4 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400B 5 Important, but can't do or no choice   Typical pattern CD   54699-4 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400B 9 No response or non-responsive   Typical pattern CD   54699-4 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0400C   Res interview: choose tub, bath, shower, sponge   Typical pattern CD   54700-0   1.3.6.1.4.1.12009.10.1.33
  F0400C 1 Very important   Typical pattern CD   54700-0 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400C 2 Somewhat important   Typical pattern CD   54700-0 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400C 3 Not very important   Typical pattern CD   54700-0 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400C 4 Not important at all   Typical pattern CD   54700-0 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400C 5 Important, but can't do or no choice   Typical pattern CD   54700-0 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400C 9 No response or non-responsive   Typical pattern CD   54700-0 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0400D   Res interview: have snacks between meals   Typical pattern CD   54701-8   1.3.6.1.4.1.12009.10.1.33
  F0400D 1 Very important   Typical pattern CD   54701-8 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400D 2 Somewhat important   Typical pattern CD   54701-8 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400D 3 Not very important   Typical pattern CD   54701-8 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400D 4 Not important at all   Typical pattern CD   54701-8 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400D 5 Important, but can't do or no choice   Typical pattern CD   54701-8 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400D 9 No response or non-responsive   Typical pattern CD   54701-8 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0400E   Res interview: choose own bedtime   Typical pattern CD   54702-6   1.3.6.1.4.1.12009.10.1.33
  F0400E 1 Very important   Typical pattern CD   54702-6 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400E 2 Somewhat important   Typical pattern CD   54702-6 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400E 3 Not very important   Typical pattern CD   54702-6 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400E 4 Not important at all   Typical pattern CD   54702-6 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400E 5 Important, but can't do or no choice   Typical pattern CD   54702-6 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400E 9 No response or non-responsive   Typical pattern CD   54702-6 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0400F   Res interview: discuss care with family/friend   Typical pattern CD   54703-4   1.3.6.1.4.1.12009.10.1.33
  F0400F 1 Very important   Typical pattern CD   54703-4 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400F 2 Somewhat important   Typical pattern CD   54703-4 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400F 3 Not very important   Typical pattern CD   54703-4 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400F 4 Not important at all   Typical pattern CD   54703-4 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400F 5 Important, but can't do or no choice   Typical pattern CD   54703-4 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400F 9 No response or non-responsive   Typical pattern CD   54703-4 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0400G   Res interview: use phone in private   Typical pattern CD   54704-2   1.3.6.1.4.1.12009.10.1.33
  F0400G 1 Very important   Typical pattern CD   54704-2 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400G 2 Somewhat important   Typical pattern CD   54704-2 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400G 3 Not very important   Typical pattern CD   54704-2 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400G 4 Not important at all   Typical pattern CD   54704-2 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400G 5 Important, but can't do or no choice   Typical pattern CD   54704-2 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400G 9 No response or non-responsive   Typical pattern CD   54704-2 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0400H   Res interview: lock things to keep them safe   Typical pattern CD   54705-9   1.3.6.1.4.1.12009.10.1.33
  F0400H 1 Very important   Typical pattern CD   54705-9 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0400H 2 Somewhat important   Typical pattern CD   54705-9 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0400H 3 Not very important   Typical pattern CD   54705-9 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0400H 4 Not important at all   Typical pattern CD   54705-9 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0400H 5 Important, but can't do or no choice   Typical pattern CD   54705-9 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0400H 9 No response or non-responsive   Typical pattern CD   54705-9 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500A   Res interview: have books, newspaper, mags to read   Typical pattern CD   54706-7   1.3.6.1.4.1.12009.10.1.33
  F0500A 1 Very important   Typical pattern CD   54706-7 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500A 2 Somewhat important   Typical pattern CD   54706-7 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500A 3 Not very important   Typical pattern CD   54706-7 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500A 4 Not important at all   Typical pattern CD   54706-7 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500A 5 Important, but can't do or no choice   Typical pattern CD   54706-7 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500A 9 No response or non-responsive   Typical pattern CD   54706-7 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500B   Res interview: listen to music   Typical pattern CD   54707-5   1.3.6.1.4.1.12009.10.1.33
  F0500B 1 Very important   Typical pattern CD   54707-5 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500B 2 Somewhat important   Typical pattern CD   54707-5 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500B 3 Not very important   Typical pattern CD   54707-5 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500B 4 Not important at all   Typical pattern CD   54707-5 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500B 5 Important, but can't do or no choice   Typical pattern CD   54707-5 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500B 9 No response or non-responsive   Typical pattern CD   54707-5 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500C   Res interview: be around animals/pets   Typical pattern CD   54708-3   1.3.6.1.4.1.12009.10.1.33
  F0500C 1 Very important   Typical pattern CD   54708-3 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500C 2 Somewhat important   Typical pattern CD   54708-3 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500C 3 Not very important   Typical pattern CD   54708-3 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500C 4 Not important at all   Typical pattern CD   54708-3 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500C 5 Important, but can't do or no choice   Typical pattern CD   54708-3 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500C 9 No response or non-responsive   Typical pattern CD   54708-3 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500D   Res interview: keep up with news   Typical pattern CD   54709-1   1.3.6.1.4.1.12009.10.1.33
  F0500D 1 Very important   Typical pattern CD   54709-1 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500D 2 Somewhat important   Typical pattern CD   54709-1 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500D 3 Not very important   Typical pattern CD   54709-1 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500D 4 Not important at all   Typical pattern CD   54709-1 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500D 5 Important, but can't do or no choice   Typical pattern CD   54709-1 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500D 9 No response or non-responsive   Typical pattern CD   54709-1 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500E   Res interview: do things with groups of people   Typical pattern CD   54710-9   1.3.6.1.4.1.12009.10.1.33
  F0500E 1 Very important   Typical pattern CD   54710-9 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500E 2 Somewhat important   Typical pattern CD   54710-9 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500E 3 Not very important   Typical pattern CD   54710-9 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500E 4 Not important at all   Typical pattern CD   54710-9 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500E 5 Important, but can't do or no choice   Typical pattern CD   54710-9 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500E 9 No response or non-responsive   Typical pattern CD   54710-9 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500F   Res interview: do favorite activities   Typical pattern CD   54711-7   1.3.6.1.4.1.12009.10.1.33
  F0500F 1 Very important   Typical pattern CD   54711-7 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500F 2 Somewhat important   Typical pattern CD   54711-7 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500F 3 Not very important   Typical pattern CD   54711-7 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500F 4 Not important at all   Typical pattern CD   54711-7 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500F 5 Important, but can't do or no choice   Typical pattern CD   54711-7 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500F 9 No response or non-responsive   Typical pattern CD   54711-7 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500G   Res interview: go outside when good weather   Typical pattern CD   54712-5   1.3.6.1.4.1.12009.10.1.33
  F0500G 1 Very important   Typical pattern CD   54712-5 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500G 2 Somewhat important   Typical pattern CD   54712-5 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500G 3 Not very important   Typical pattern CD   54712-5 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500G 4 Not important at all   Typical pattern CD   54712-5 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500G 5 Important, but can't do or no choice   Typical pattern CD   54712-5 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500G 9 No response or non-responsive   Typical pattern CD   54712-5 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0500H   Res interview: participate in religious practices   Typical pattern CD   54713-3   1.3.6.1.4.1.12009.10.1.33
  F0500H 1 Very important   Typical pattern CD   54713-3 LA11013-2 1.3.6.1.4.1.12009.10.1.33
  F0500H 2 Somewhat important   Typical pattern CD   54713-3 LA11014-0 1.3.6.1.4.1.12009.10.1.33
  F0500H 3 Not very important   Typical pattern CD   54713-3 LA11015-7 1.3.6.1.4.1.12009.10.1.33
  F0500H 4 Not important at all   Typical pattern CD   54713-3 LA11016-5 1.3.6.1.4.1.12009.10.1.33
  F0500H 5 Important, but can't do or no choice   Typical pattern CD   54713-3 LA11017-3 1.3.6.1.4.1.12009.10.1.33
  F0500H 9 No response or non-responsive   Typical pattern CD   54713-3 LA11018-1 1.3.6.1.4.1.12009.10.1.33
  F0600   Primary respondent: daily/ activities prefs   Typical pattern CD   54714-1   1.3.6.1.4.1.12009.10.1.7
  F0600 1 Resident   Typical pattern CD   54714-1 LA11019-9 1.3.6.1.4.1.12009.10.1.7
  F0600 2 Family or significant other (close friend or other representative)   Typical pattern CD   54714-1 LA11020-7 1.3.6.1.4.1.12009.10.1.7
  F0600 9 Interview could not be completed by resident or family/ significant other (“No Response” to 3 or more items)   Typical pattern CD   54714-1 LA11021-5 1.3.6.1.4.1.12009.10.1.7
  F0700   Conduct staff assessment for daily/activity prefs   Typical pattern CD   54715-8   1.3.6.1.4.1.12009.10.1.1
  F0700 0 No (because Interview for Daily and Activity Preferences (F0400 and F0500) was completed by resident or family/significant other)   Typical pattern CD   54715-8 LA11151-0 1.3.6.1.4.1.12009.10.1.1
  F0700 1 Yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident or family/significant other)   Typical pattern CD   54715-8 LA11152-8 1.3.6.1.4.1.12009.10.1.1
  F0800A   Staff assessment: choosing clothes to wear   Multiple response pattern BL   54716-6    
  F0800B   Staff assessment: caring for personal belongings   Multiple response pattern BL   54717-4    
  F0800C   Staff assessment: receiving tub bath   Multiple response pattern BL   54718-2    
  F0800D   Staff assessment: receiving shower   Multiple response pattern BL   54719-0    
  F0800E   Staff assessment: receiving bed bath   Multiple response pattern BL   54720-8    
  F0800F   Staff assessment: receiving sponge bath   Multiple response pattern BL   54721-6    
  F0800G   Staff assessment: snacks between meals   Multiple response pattern BL   54722-4    
  F0800H   Staff assessment: staying up past 8PM   Multiple response pattern BL   54723-2    
  F0800I   Staff assessment: discuss care with family/other   Multiple response pattern BL   54724-0    
  F0800J   Staff assessment: use phone in private   Multiple response pattern BL   54725-7    
  F0800K   Staff assessment: place to lock personal things   Multiple response pattern BL   54726-5    
  F0800L   Staff assessment: reading books, newspapers, mags   Multiple response pattern BL   54727-3    
  F0800M   Staff assessment: listening to music   Multiple response pattern BL   54728-1    
  F0800N   Staff assessment: being around animals/pets   Multiple response pattern BL   54729-9    
  F0800O   Staff assessment: keeping up with news   Multiple response pattern BL   54730-7    
  F0800P   Staff assessment: doing things with groups   Multiple response pattern BL   54731-5    
  F0800Q   Staff assessment: participate favorite activities   Multiple response pattern BL   54732-3    
  F0800R   Staff assessment: spend time away from nursing home   Multiple response pattern BL   54733-1    
  F0800S   Staff assessment: spend time outdoors   Multiple response pattern BL   54734-9    
  F0800T   Staff assessment: participate religious activities   Multiple response pattern BL   54735-6    
  F0800Z   Staff assessment: none of above activities   Multiple response pattern BL   54736-4    
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
G     Functional Status              
  G0110A1   Bed mobility: self-performance   Typical pattern CD   45588-1   1.3.6.1.4.1.12009.10.1.70
  G0110A1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45588-1 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110A1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45588-1 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110A1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45588-1 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110A1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45588-1 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110A1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45588-1 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110A1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45588-1 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  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   Typical pattern CD   45588-1 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110A2   Bed mobility: support provided   Typical pattern CD   45589-9   1.3.6.1.4.1.12009.10.1.160
  G0110A2 0 No setup or physical help from staff   Typical pattern CD   45589-9 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110A2 1 Setup help only   Typical pattern CD   45589-9 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110A2 2 One person physical assist   Typical pattern CD   45589-9 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110A2 3 Two+ persons physical assist   Typical pattern CD   45589-9 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110A2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45589-9 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110B1   Transfer: self-performance   Typical pattern CD   45590-7   1.3.6.1.4.1.12009.10.1.70
  G0110B1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45590-7 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110B1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45590-7 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110B1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45590-7 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110B1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45590-7 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110B1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45590-7 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110B1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45590-7 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  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   Typical pattern CD   45590-7 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110B2   Transfer: support provided   Typical pattern CD   45591-5   1.3.6.1.4.1.12009.10.1.160
  G0110B2 0 No setup or physical help from staff   Typical pattern CD   45591-5 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110B2 1 Setup help only   Typical pattern CD   45591-5 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110B2 2 One person physical assist   Typical pattern CD   45591-5 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110B2 3 Two+ persons physical assist   Typical pattern CD   45591-5 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110B2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45591-5 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110C1   Walk in room: self-performance   Typical pattern CD   45592-3   1.3.6.1.4.1.12009.10.1.70
  G0110C1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45592-3 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110C1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45592-3 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110C1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45592-3 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110C1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45592-3 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110C1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45592-3 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110C1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45592-3 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  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   Typical pattern CD   45592-3 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110C2   Walk in room: support provided   Typical pattern CD   45593-1   1.3.6.1.4.1.12009.10.1.160
  G0110C2 0 No setup or physical help from staff   Typical pattern CD   45593-1 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110C2 1 Setup help only   Typical pattern CD   45593-1 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110C2 2 One person physical assist   Typical pattern CD   45593-1 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110C2 3 Two+ persons physical assist   Typical pattern CD   45593-1 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110C2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45593-1 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110D1   Walk in corridor: self-performance   Typical pattern CD   45594-9   1.3.6.1.4.1.12009.10.1.70
  G0110D1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45594-9 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110D1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45594-9 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110D1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45594-9 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110D1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45594-9 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110D1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45594-9 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110D1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45594-9 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  G0110D1 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   Typical pattern CD   45594-9 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110D2   Walk in corridor: support provided   Typical pattern CD   45595-6   1.3.6.1.4.1.12009.10.1.160
  G0110D2 0 No setup or physical help from staff   Typical pattern CD   45595-6 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110D2 1 Setup help only   Typical pattern CD   45595-6 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110D2 2 One person physical assist   Typical pattern CD   45595-6 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110D2 3 Two+ persons physical assist   Typical pattern CD   45595-6 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110D2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45595-6 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110E1   Locomotion on unit: self-performance   Typical pattern CD   45596-4   1.3.6.1.4.1.12009.10.1.70
  G0110E1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45596-4 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110E1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45596-4 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110E1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45596-4 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110E1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45596-4 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110E1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45596-4 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110E1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45596-4 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  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   Typical pattern CD   45596-4 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110E2   Locomotion on unit: support provided   Typical pattern CD   45597-2   1.3.6.1.4.1.12009.10.1.160
  G0110E2 0 No setup or physical help from staff   Typical pattern CD   45597-2 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110E2 1 Setup help only   Typical pattern CD   45597-2 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110E2 2 One person physical assist   Typical pattern CD   45597-2 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110E2 3 Two+ persons physical assist   Typical pattern CD   45597-2 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110E2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45597-2 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110F1   Locomotion off unit: self-performance   Typical pattern CD   45598-0   1.3.6.1.4.1.12009.10.1.70
  G0110F1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45598-0 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110F1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45598-0 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110F1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45598-0 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110F1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45598-0 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110F1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45598-0 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110F1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45598-0 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  G0110F1 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   Typical pattern CD   45598-0 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110F2   Locomotion off unit: support provided   Typical pattern CD   45599-8   1.3.6.1.4.1.12009.10.1.160
  G0110F2 0 No setup or physical help from staff   Typical pattern CD   45599-8 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110F2 1 Setup help only   Typical pattern CD   45599-8 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110F2 2 One person physical assist   Typical pattern CD   45599-8 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110F2 3 Two+ persons physical assist   Typical pattern CD   45599-8 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110F2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45599-8 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110G1   Dressing: self-performance   Typical pattern CD   45600-4   1.3.6.1.4.1.12009.10.1.70
  G0110G1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45600-4 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110G1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45600-4 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110G1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45600-4 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110G1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45600-4 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110G1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45600-4 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110G1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45600-4 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  G0110G1 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   Typical pattern CD   45600-4 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110G2   Dressing: support provided   Typical pattern CD   45601-2   1.3.6.1.4.1.12009.10.1.160
  G0110G2 0 No setup or physical help from staff   Typical pattern CD   45601-2 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110G2 1 Setup help only   Typical pattern CD   45601-2 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110G2 2 One person physical assist   Typical pattern CD   45601-2 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110G2 3 Two+ persons physical assist   Typical pattern CD   45601-2 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110G2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45601-2 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110H1   Eating: self-performance   Typical pattern CD   45602-0   1.3.6.1.4.1.12009.10.1.70
  G0110H1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45602-0 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110H1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45602-0 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110H1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45602-0 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110H1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45602-0 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110H1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45602-0 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110H1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45602-0 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  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   Typical pattern CD   45602-0 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110H2   Eating: support provided   Typical pattern CD   45603-8   1.3.6.1.4.1.12009.10.1.160
  G0110H2 0 No setup or physical help from staff   Typical pattern CD   45603-8 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110H2 1 Setup help only   Typical pattern CD   45603-8 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110H2 2 One person physical assist   Typical pattern CD   45603-8 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110H2 3 Two+ persons physical assist   Typical pattern CD   45603-8 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110H2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45603-8 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110I1   Toilet use: self-performance   Typical pattern CD   45604-6   1.3.6.1.4.1.12009.10.1.70
  G0110I1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45604-6 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110I1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45604-6 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110I1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45604-6 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110I1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45604-6 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110I1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45604-6 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110I1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45604-6 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  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   Typical pattern CD   45604-6 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110I2   Toilet use: support provided   Typical pattern CD   45605-3   1.3.6.1.4.1.12009.10.1.160
  G0110I2 0 No setup or physical help from staff   Typical pattern CD   45605-3 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110I2 1 Setup help only   Typical pattern CD   45605-3 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110I2 2 One person physical assist   Typical pattern CD   45605-3 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110I2 3 Two+ persons physical assist   Typical pattern CD   45605-3 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110I2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45605-3 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0110J1   Personal hygiene: self-performance   Typical pattern CD   45606-1   1.3.6.1.4.1.12009.10.1.70
  G0110J1 0 Independent - no help or staff oversight at any time   Typical pattern CD   45606-1 LA12637-7 1.3.6.1.4.1.12009.10.1.70
  G0110J1 1 Supervision - oversight, encouragement or cueing   Typical pattern CD   45606-1 LA12638-5 1.3.6.1.4.1.12009.10.1.70
  G0110J1 2 Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance   Typical pattern CD   45606-1 LA12639-3 1.3.6.1.4.1.12009.10.1.70
  G0110J1 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support   Typical pattern CD   45606-1 LA12640-1 1.3.6.1.4.1.12009.10.1.70
  G0110J1 4 Total dependence - full staff performance every time during entire 7-day period   Typical pattern CD   45606-1 LA12641-9 1.3.6.1.4.1.12009.10.1.70
  G0110J1 7 Activity occurred only once or twice - activity did occur but only once or twice.   Typical pattern CD   45606-1 LA12642-7 1.3.6.1.4.1.12009.10.1.70
  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   Typical pattern CD   45606-1 LA12643-5 1.3.6.1.4.1.12009.10.1.70
  G0110J2   Personal hygiene: support provided   Typical pattern CD   45607-9   1.3.6.1.4.1.12009.10.1.160
  G0110J2 0 No setup or physical help from staff   Typical pattern CD   45607-9 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0110J2 1 Setup help only   Typical pattern CD   45607-9 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0110J2 2 One person physical assist   Typical pattern CD   45607-9 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0110J2 3 Two+ persons physical assist   Typical pattern CD   45607-9 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0110J2 8 ADL activity itself did not occur during entire period   Typical pattern CD   45607-9 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0120A   Bathing: self-performance   Typical pattern CD   45608-7   1.3.6.1.4.1.12009.10.1.161
  G0120A 0 Independent - no help provided   Typical pattern CD   45608-7 LA110-9 1.3.6.1.4.1.12009.10.1.161
  G0120A 1 Supervision - oversight help only   Typical pattern CD   45608-7 LA111-7 1.3.6.1.4.1.12009.10.1.161
  G0120A 2 Physical help limited to transfer only   Typical pattern CD   45608-7 LA112-5 1.3.6.1.4.1.12009.10.1.161
  G0120A 3 Physical help in part of bathing activity   Typical pattern CD   45608-7 LA113-3 1.3.6.1.4.1.12009.10.1.161
  G0120A 4 Total dependence   Typical pattern CD   45608-7 LA114-1 1.3.6.1.4.1.12009.10.1.161
  G0120A 8 Activity did not occur during the entire period   Typical pattern CD   45608-7 LA115-8 1.3.6.1.4.1.12009.10.1.161
  G0120B   Bathing: support provided   Typical pattern CD   45609-5   1.3.6.1.4.1.12009.10.1.160
  G0120B 0 No setup or physical help from staff   Typical pattern CD   45609-5 LA105-9 1.3.6.1.4.1.12009.10.1.160
  G0120B 1 Setup help only   Typical pattern CD   45609-5 LA106-7 1.3.6.1.4.1.12009.10.1.160
  G0120B 2 One person physical assist   Typical pattern CD   45609-5 LA107-5 1.3.6.1.4.1.12009.10.1.160
  G0120B 3 Two+ persons physical assist   Typical pattern CD   45609-5 LA108-3 1.3.6.1.4.1.12009.10.1.160
  G0120B 8 ADL activity itself did not occur during entire period   Typical pattern CD   45609-5 LA109-1 1.3.6.1.4.1.12009.10.1.160
  G0300A   Balance: moving from seated to standing position   Typical pattern CD   54749-7   1.3.6.1.4.1.12009.10.1.31
  G0300A 0 Steady at all times   Typical pattern CD   54749-7 LA11031-4 1.3.6.1.4.1.12009.10.1.31
  G0300A 1 Not steady, but able to stabilize without human assistance   Typical pattern CD   54749-7 LA11032-2 1.3.6.1.4.1.12009.10.1.31
  G0300A 2 Not steady, only able to stabilize with human assistance   Typical pattern CD   54749-7 LA11033-0 1.3.6.1.4.1.12009.10.1.31
  G0300A 8 Activity did not occur   Typical pattern CD   54749-7 LA11034-8 1.3.6.1.4.1.12009.10.1.31
  G0300B   Balance: walking (with assistive device if used)   Typical pattern CD   54750-5   1.3.6.1.4.1.12009.10.1.31
  G0300B 0 Steady at all times   Typical pattern CD   54750-5 LA11031-4 1.3.6.1.4.1.12009.10.1.31
  G0300B 1 Not steady, but able to stabilize without human assistance   Typical pattern CD   54750-5 LA11032-2 1.3.6.1.4.1.12009.10.1.31
  G0300B 2 Not steady, only able to stabilize with human assistance   Typical pattern CD   54750-5 LA11033-0 1.3.6.1.4.1.12009.10.1.31
  G0300B 8 Activity did not occur   Typical pattern CD   54750-5 LA11034-8 1.3.6.1.4.1.12009.10.1.31
  G0300C   Balance: turning around while walking   Typical pattern CD   54751-3   1.3.6.1.4.1.12009.10.1.31
  G0300C 0 Steady at all times   Typical pattern CD   54751-3 LA11031-4 1.3.6.1.4.1.12009.10.1.31
  G0300C 1 Not steady, but able to stabilize without human assistance   Typical pattern CD   54751-3 LA11032-2 1.3.6.1.4.1.12009.10.1.31
  G0300C 2 Not steady, only able to stabilize with human assistance   Typical pattern CD   54751-3 LA11033-0 1.3.6.1.4.1.12009.10.1.31
  G0300C 8 Activity did not occur   Typical pattern CD   54751-3 LA11034-8 1.3.6.1.4.1.12009.10.1.31
  G0300D   Balance: moving on and off toilet   Typical pattern CD   54752-1   1.3.6.1.4.1.12009.10.1.31
  G0300D 0 Steady at all times   Typical pattern CD   54752-1 LA11031-4 1.3.6.1.4.1.12009.10.1.31
  G0300D 1 Not steady, but able to stabilize without human assistance   Typical pattern CD   54752-1 LA11032-2 1.3.6.1.4.1.12009.10.1.31
  G0300D 2 Not steady, only able to stabilize with human assistance   Typical pattern CD   54752-1 LA11033-0 1.3.6.1.4.1.12009.10.1.31
  G0300D 8 Activity did not occur   Typical pattern CD   54752-1 LA11034-8 1.3.6.1.4.1.12009.10.1.31
  G0300E   Balance: surface-to-surface transfer   Typical pattern CD   54753-9   1.3.6.1.4.1.12009.10.1.31
  G0300E 0 Steady at all times   Typical pattern CD   54753-9 LA11031-4 1.3.6.1.4.1.12009.10.1.31
  G0300E 1 Not steady, but able to stabilize without human assistance   Typical pattern CD   54753-9 LA11032-2 1.3.6.1.4.1.12009.10.1.31
  G0300E 2 Not steady, only able to stabilize with human assistance   Typical pattern CD   54753-9 LA11033-0 1.3.6.1.4.1.12009.10.1.31
  G0300E 8 Activity did not occur   Typical pattern CD   54753-9 LA11034-8 1.3.6.1.4.1.12009.10.1.31
  G0400A   ROM limitation: upper extremity   Typical pattern CD   54754-7   1.3.6.1.4.1.12009.10.1.36
  G0400A 0 No impairment   Typical pattern CD   54754-7 LA9606-0 1.3.6.1.4.1.12009.10.1.36
  G0400A 1 Impairment on one side   Typical pattern CD   54754-7 LA11036-3 1.3.6.1.4.1.12009.10.1.36
  G0400A 2 Impairment on both sides   Typical pattern CD   54754-7 LA11037-1 1.3.6.1.4.1.12009.10.1.36
  G0400B   ROM limitation: lower extremity   Typical pattern CD   54755-4   1.3.6.1.4.1.12009.10.1.36
  G0400B 0 No impairment   Typical pattern CD   54755-4 LA9606-0 1.3.6.1.4.1.12009.10.1.36
  G0400B 1 Impairment on one side   Typical pattern CD   54755-4 LA11036-3 1.3.6.1.4.1.12009.10.1.36
  G0400B 2 Impairment on both sides   Typical pattern CD   54755-4 LA11037-1 1.3.6.1.4.1.12009.10.1.36
  G0600A   Mobility devices: cane/crutch   Multiple response pattern BL   54756-2    
  G0600B   Mobility devices: walker   Multiple response pattern BL   54757-0    
  G0600C   Mobility devices: wheelchair (manual or electric)   Multiple response pattern BL   54758-8    
  G0600D   Mobility devices: limb prosthesis   Multiple response pattern BL   54759-6    
  G0600Z   Mobility devices: none of the above   Multiple response pattern BL   54760-4    
  G0900A   Resident believes capable of increased independ   Typical pattern CD   55123-4   1.3.6.1.4.1.12009.10.1.58
  G0900A 0 No   Typical pattern CD   55123-4 LA32-8 1.3.6.1.4.1.12009.10.1.58
  G0900A 1 Yes   Typical pattern CD   55123-4 LA33-6 1.3.6.1.4.1.12009.10.1.58
  G0900A 9 Unable to determine   Typical pattern CD   55123-4 LA11137-9 1.3.6.1.4.1.12009.10.1.58
  G0900B   Staff believes res capable of increased independ   Typical pattern CD   45613-7   1.3.6.1.4.1.12009.10.1.62
  G0900B 0 No   Typical pattern CD   45613-7 LA32-8 1.3.6.1.4.1.12009.10.1.62
  G0900B 1 Yes   Typical pattern CD   45613-7 LA33-6 1.3.6.1.4.1.12009.10.1.62
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
H     Bladder and Bowel              
  H0100A   Appliances: indwelling catheter   Multiple response pattern BL   54762-0    
  H0100B   Appliances: external catheter   Multiple response pattern BL   54763-8    
  H0100C   Appliances: ostomy   Multiple response pattern BL   54764-6    
  H0100D   Appliances: intermittent catheterization   Multiple response pattern BL   54765-3    
  H0100Z   Appliances: none of the above   Multiple response pattern BL   54766-1    
  H0200A   Urinary toileting program: has been attempted   Typical pattern CD   54767-9   1.3.6.1.4.1.12009.10.1.58
  H0200A 0 No   Typical pattern CD   54767-9 LA32-8 1.3.6.1.4.1.12009.10.1.58
  H0200A 1 Yes   Typical pattern CD   54767-9 LA33-6 1.3.6.1.4.1.12009.10.1.58
  H0200A 9 Unable to determine     Typical pattern CD   54767-9 LA11137-9 1.3.6.1.4.1.12009.10.1.58
  H0200B   Urinary toileting program: response   Typical pattern CD   54768-7   1.3.6.1.4.1.12009.10.1.30
  H0200B 0 No improvement   Typical pattern CD   54768-7 LA11038-9 1.3.6.1.4.1.12009.10.1.30
  H0200B 1 Decreased wetness   Typical pattern CD   54768-7 LA11039-7 1.3.6.1.4.1.12009.10.1.30
  H0200B 2 Completely dry (continent)   Typical pattern CD   54768-7 LA11040-5 1.3.6.1.4.1.12009.10.1.30
  H0200B 9 Unable to determine or trial in progress   Typical pattern CD   54768-7 LA11041-3 1.3.6.1.4.1.12009.10.1.30
  H0200C   Urinary toileting program: current program/trial   Typical pattern CD   54769-5   1.3.6.1.4.1.12009.10.1.62
  H0200C 0 No   Typical pattern CD   54769-5 LA32-8 1.3.6.1.4.1.12009.10.1.62
  H0200C 1 Yes   Typical pattern CD   54769-5 LA33-6 1.3.6.1.4.1.12009.10.1.62
  H0300   Urinary continence   Typical pattern CD   54770-3   1.3.6.1.4.1.12009.10.1.29
  H0300 0 Always continent   Typical pattern CD   54770-3 LA11042-1 1.3.6.1.4.1.12009.10.1.29
  H0300 1 Occasionally incontinent (less than 7 episodes of incontinence)   Typical pattern CD   54770-3 LA11043-9 1.3.6.1.4.1.12009.10.1.29
  H0300 2 Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding)   Typical pattern CD   54770-3 LA11044-7 1.3.6.1.4.1.12009.10.1.29
  H0300 3 Always incontinent (no episodes of continent voiding)   Typical pattern CD   54770-3 LA11045-4 1.3.6.1.4.1.12009.10.1.29
  H0300 9 Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for entire 7 days   Typical pattern CD   54770-3 LA11046-2 1.3.6.1.4.1.12009.10.1.29
  H0400   Bowel continence   Typical pattern CD   54771-1    1.3.6.1.4.1.12009.10.1.28
  H0400 0 Always continent   Typical pattern CD   54771-1 LA11042-1 1.3.6.1.4.1.12009.10.1.28
  H0400 1 Occasionally incontinent (one episode of bowel incontinence)   Typical pattern CD   54771-1 LA11048-8 1.3.6.1.4.1.12009.10.1.28
  H0400 2 Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)   Typical pattern CD   54771-1 LA11049-6 1.3.6.1.4.1.12009.10.1.28
  H0400 3 Always incontinent (no episodes of continent bowel movements)   Typical pattern CD   54771-1 LA11050-4 1.3.6.1.4.1.12009.10.1.28
  H0400 9 Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days   Typical pattern CD   54771-1 LA11051-2 1.3.6.1.4.1.12009.10.1.28
  H0500   Bowel toileting program being used   Typical pattern CD   54772-9   1.3.6.1.4.1.12009.10.1.62
  H0500 0 No   Typical pattern CD   54772-9 LA32-8 1.3.6.1.4.1.12009.10.1.62
  H0500 1 Yes   Typical pattern CD   54772-9 LA33-6 1.3.6.1.4.1.12009.10.1.62
  H0600   Constipation   Typical pattern CD   54773-7   1.3.6.1.4.1.12009.10.1.62
  H0600 0 No   Typical pattern CD   54773-7 LA32-8 1.3.6.1.4.1.12009.10.1.62
  H0600 1 Yes   Typical pattern CD   54773-7 LA33-6 1.3.6.1.4.1.12009.10.1.62
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
I     Active Disease Diagnosis              
  I0100   Cancer (with or without metastasis)   Multiple response pattern BL   54774-5    
  I0200   Anemia   Multiple response pattern BL   54775-2    
  I0300   Atrial fibrillation and other dysrhythmias   Multiple response pattern BL   54776-0    
  I0400   Coronary artery disease (CAD)   Multiple response pattern BL   54777-8    
  I0500   Deep venous thrombosis (DVT), PE, or PTE   Multiple response pattern BL   54778-6    
  I0600   Heart failure   Multiple response pattern BL   54779-4    
  I0700   Hypertension   Multiple response pattern BL   54780-2    
  I0800   Orthostatic hypotension   Multiple response pattern BL   54781-0    
  I0900   Peripheral vascular disease (PVD) or PAD   Multiple response pattern BL   54782-8    
  I1100   Cirrhosis   Multiple response pattern BL   54783-6    
  I1200   Gastroesophageal reflux disease (GERD) or ulcer   Multiple response pattern BL   54784-4    
  I1300   Ulcerative colitis, Crohn’s, inflam bowel disease   Multiple response pattern BL   54785-1    
  I1400   Benign prostatic hyperplasia (BPH)   Multiple response pattern BL   54786-9    
  I1500   Renal insufficiency, renal failure, ESRD   Multiple response pattern BL   54787-7    
  I1550   Neurogenic bladder   Multiple response pattern BL   58111-6    
  I1650   Obstructive uropathy   Multiple response pattern BL   58112-4    
  I1700   Multidrug resistant organism (MDRO)   Multiple response pattern BL   58109-0    
  I2000   Pneumonia   Multiple response pattern BL   54790-1    
  I2100   Septicemia   Multiple response pattern BL   54791-9    
  I2200   Tuberculosis   Multiple response pattern BL   54792-7    
  I2300   Urinary tract infection (UTI) (LAST 30 DAYS)   Multiple response pattern BL   54793-5    
  I2400   Viral hepatitis (includes type A, B, C, D, and E)   Multiple response pattern BL   54794-3    
  I2500   Wound infection (other than foot)   Multiple response pattern BL   54965-9    
  I2900   Diabetes mellitus (DM)   Multiple response pattern BL   54795-0    
  I3100   Hyponatremia   Multiple response pattern BL   54796-8    
  I3200   Hyperkalemia   Multiple response pattern BL   54797-6    
  I3300   Hyperlipidemia (e.g.,  hypercholesterolemia)   Multiple response pattern BL   54798-4    
  I3400   Thyroid disorder   Multiple response pattern BL   54799-2    
  I3700   Arthritis   Multiple response pattern BL   54800-8    
  I3800   Osteoporosis   Multiple response pattern BL   54801-6    
  I3900   Hip fracture   Multiple response pattern BL   54802-4    
  I4000   Other fracture   Multiple response pattern BL   54803-2    
  I4200   Alzheimer's disease   Multiple response pattern BL   54804-0    
  I4300   Aphasia   Multiple response pattern BL   54805-7    
  I4400   Cerebral palsy   Multiple response pattern BL   54806-5    
  I4500   Cerebrovascular accident (CVA), TIA, or stroke   Multiple response pattern BL   54807-3    
  I4800   Dementia   Multiple response pattern BL   54808-1    
  I4900   Hemiplegia or hemiparesis   Multiple response pattern BL   54809-9    
  I5000   Paraplegia   Multiple response pattern BL   54810-7    
  I5100   Quadriplegia   Multiple response pattern BL   54811-5    
  I5200   Multiple sclerosis   Multiple response pattern BL   54812-3    
  I5250   Huntington's disease   Multiple response pattern BL   58113-2    
  I5300   Parkinson's disease   Multiple response pattern BL   54813-1    
  I5350   Tourette's syndrome   Multiple response pattern BL   58114-0    
  I5400   Seizure disorder or epilepsy   Multiple response pattern BL   54814-9    
  I5500   Traumatic brain injury (TBI)   Multiple response pattern BL   54815-6    
  I5600   Malnutrition (protein, calorie), risk of malnutrit   Multiple response pattern BL   54816-4    
  I5700   Anxiety disorder   Multiple response pattern BL    54817-2    
  I5800   Depression (other than bipolar)   Multiple response pattern BL   54818-0    
  I5900   Manic depression (bipolar disease)   Multiple response pattern BL   54819-8    
  I5950   Psychotic disorder (other than schizophrenia)   Multiple response pattern BL   58115-7    
  I6000   Schizophrenia   Multiple response pattern BL   54820-6    
  I6100   Post-traumatic stress disorder (PTSD)   Multiple response pattern BL   54821-4    
  I6200   Asthma (COPD) or chronic lung disease   Multiple response pattern BL   54822-2    
  I6300   Respiratory failure   Multiple response pattern BL   58116-5    
  I6500   Cataracts, glaucoma, or macular degeneration   Multiple response pattern BL   54823-0    
  I7900   None of above active diseases within last 7 days   Multiple response pattern BL   54824-8    
  I8000A   Additional active ICD diagnosis 1   Other response data type pattern CD   54546-7    
  I8000B   Additional active ICD diagnosis 2   Other response data type pattern CD   54547-5    
  I8000C   Additional active ICD diagnosis 3   Other response data type pattern CD   54548-3    
  I8000D   Additional active ICD diagnosis 4   Other response data type pattern CD   54549-1    
  I8000E   Additional active ICD diagnosis 5   Other response data type pattern CD   54550-9    
  I8000F   Additional active ICD diagnosis 6   Other response data type pattern CD   54551-7    
  I8000G   Additional active ICD diagnosis 7   Other response data type pattern CD   54552-5    
  I8000H   Additional active ICD diagnosis 8   Other response data type pattern CD   54553-3    
  I8000I   Additional active ICD diagnosis 9   Other response data type pattern CD   54554-1    
  I8000J   Additional active ICD diagnosis 10   Other response data type pattern CD   54555-8    
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
J     Health Conditions              
  J0100A   Pain: been on scheduled pain med regimen   Typical pattern CD   54825-5   1.3.6.1.4.1.12009.10.1.62
  J0100A 0 No   Typical pattern CD   54825-5 LA32-8 1.3.6.1.4.1.12009.10.1.62
  J0100A 1 Yes   Typical pattern CD   54825-5 LA33-6 1.3.6.1.4.1.12009.10.1.62
  J0100B   Pain: received PRN pain medications   Typical pattern CD   54826-3   1.3.6.1.4.1.12009.10.1.62
  J0100B 0 No   Typical pattern CD   54826-3 LA32-8 1.3.6.1.4.1.12009.10.1.62
  J0100B 1 Yes   Typical pattern CD   54826-3 LA33-6 1.3.6.1.4.1.12009.10.1.62
  J0100C   Pain: received non-medication intervention   Typical pattern CD   54827-1   1.3.6.1.4.1.12009.10.1.62
  J0100C 0 No   Typical pattern CD   54827-1 LA32-8 1.3.6.1.4.1.12009.10.1.62
  J0100C 1 Yes   Typical pattern CD   54827-1 LA33-6 1.3.6.1.4.1.12009.10.1.62
  J0200   Should pain assessment interview be conducted   Typical pattern CD   54828-9   1.3.6.1.4.1.12009.10.1.2
  J0200 0 No (resident rarely/never understood)   Typical pattern CD   54828-9 LA11150-2 1.3.6.1.4.1.12009.10.1.2
  J0200 1 Yes   Typical pattern CD   54828-9 LA33-6 1.3.6.1.4.1.12009.10.1.2
  J0300   Res pain interview: presence   Typical pattern CD   54829-7   1.3.6.1.4.1.12009.10.1.27
  J0300 0 No   Typical pattern CD   54829-7 LA32-8 1.3.6.1.4.1.12009.10.1.27
  J0300 1 Yes   Typical pattern CD   54829-7 LA33-6 1.3.6.1.4.1.12009.10.1.27
  J0300 9 Unable to answer   Typical pattern CD   54829-7 LA11054-6 1.3.6.1.4.1.12009.10.1.27
  J0400   Res pain interview: frequency   Typical pattern CD   54830-5   1.3.6.1.4.1.12009.10.1.26
  J0400 1 Almost constantly   Typical pattern CD   54830-5 LA11055-3 1.3.6.1.4.1.12009.10.1.26
  J0400 2 Frequently   Typical pattern CD   54830-5 LA6482-9 1.3.6.1.4.1.12009.10.1.26
  J0400 3 Occasionally   Typical pattern CD   54830-5 LA6483-7 1.3.6.1.4.1.12009.10.1.26
  J0400 4 Rarely   Typical pattern CD   54830-5 LA10066-1 1.3.6.1.4.1.12009.10.1.26
  J0400 9 Unable to answer   Typical pattern CD   54830-5 LA11054-6 1.3.6.1.4.1.12009.10.1.26
  J0500A   Res pain interview: made it hard to sleep   Typical pattern CD   54831-3   1.3.6.1.4.1.12009.10.1.27
  J0500A 0 No   Typical pattern CD   54831-3 LA32-8 1.3.6.1.4.1.12009.10.1.27
  J0500A 1 Yes   Typical pattern CD   54831-3 LA33-6 1.3.6.1.4.1.12009.10.1.27
  J0500A 9 Unable to answer   Typical pattern CD   54831-3 LA11054-6 1.3.6.1.4.1.12009.10.1.27
  J0500B   Res pain interview: limited daily activities   Typical pattern CD   54832-1   1.3.6.1.4.1.12009.10.1.27
  J0500B 0 No   Typical pattern CD   54832-1 LA32-8 1.3.6.1.4.1.12009.10.1.27
  J0500B 1 Yes   Typical pattern CD   54832-1 LA33-6 1.3.6.1.4.1.12009.10.1.27
  J0500B 9 Unable to answer   Typical pattern CD   54832-1 LA11054-6 1.3.6.1.4.1.12009.10.1.27
  J0600A   Res pain interview: intensity rating scale   Other response data type pattern INT   54833-9    
  J0600B   Res pain interview: verbal descriptor scale   Typical pattern CD   54834-7   1.3.6.1.4.1.12009.10.1.25
  J0600B 1 Mild   Typical pattern CD   54834-7 LA6752-5 1.3.6.1.4.1.12009.10.1.25
  J0600B 2 Moderate   Typical pattern CD   54834-7 LA6751-7 1.3.6.1.4.1.12009.10.1.25
  J0600B 3 Severe   Typical pattern CD   54834-7 LA6750-9 1.3.6.1.4.1.12009.10.1.25
  J0600B 4 Very severe, horrible   Typical pattern CD   54834-7 LA11063-7 1.3.6.1.4.1.12009.10.1.25
  J0600B 9 Unable to answer   Typical pattern CD   54834-7 LA11054-6 1.3.6.1.4.1.12009.10.1.25
  J0700   Should staff assessment for pain be conducted   Typical pattern CD   58117-3   1.3.6.1.4.1.12009.10.1.62
  J0700 0 No (J0400=1 thru 4)   Typical pattern CD   58117-3 LA32-8 1.3.6.1.4.1.12009.10.1.62
  J0700 1 Yes (J0200=0 or J0300=9 or J0400=9)   Typical pattern CD   58117-3 LA33-6 1.3.6.1.4.1.12009.10.1.62
  J0800A   Staff pain asmt: non-verbal sounds   Multiple response pattern BL   54835-4    
  J0800B   Staff pain asmt: vocal complaints of pain   Multiple response pattern BL   54836-2    
  J0800C   Staff pain asmt: facial expressions   Multiple response pattern BL   54837-0    
  J0800D   Staff pain asmt: protective movements/postures   Multiple response pattern BL   54838-8    
  J0800Z   Staff pain asmt: none of these signs observed   Multiple response pattern BL   54839-6    
  J0850   Staff pain asmt: frequency of pain   Typical pattern CD   58118-1   1.3.6.1.4.1.12009.10.1.71
  J0850 1 Indicators of pain or possible pain observed 1 to 2 days   Typical pattern CD   58118-1 LA12645-0 1.3.6.1.4.1.12009.10.1.71
  J0850 2 Indicators of pain or possible pain observed 3 to 4 days   Typical pattern CD   58118-1 LA12646-8 1.3.6.1.4.1.12009.10.1.71
  J0850 3 Indicators of possible pain observed daily   Typical pattern CD   58118-1 LA12647-6 1.3.6.1.4.1.12009.10.1.71
  J1100A   Short breath/trouble breathing: with exertion   Multiple response pattern BL   54841-2    
  J1100B   Short breath/trouble breathing: sitting at rest   Multiple response pattern BL   54842-0    
  J1100C   Short breath/trouble breathing: lying flat   Multiple response pattern BL   54843-8    
  J1100Z   Short breath/trouble breathing: none of above   Multiple response pattern BL   54844-6    
  J1300   Current tobacco use   Typical pattern CD   54845-3   1.3.6.1.4.1.12009.10.1.62
  J1300 0 No   Typical pattern CD   54845-3 LA32-8 1.3.6.1.4.1.12009.10.1.62
  J1300 1 Yes   Typical pattern CD   54845-3 LA33-6 1.3.6.1.4.1.12009.10.1.62
  J1400   Prognosis: life expectancy of less than 6 months   Typical pattern CD   54846-1   1.3.6.1.4.1.12009.10.1.62
  J1400 0 No   Typical pattern CD   54846-1 LA32-8 1.3.6.1.4.1.12009.10.1.62
  J1400 1 Yes   Typical pattern CD   54846-1 LA33-6 1.3.6.1.4.1.12009.10.1.62
  J1550A   Problem conditions: fever   Multiple response pattern BL   45701-0    
  J1550B   Problem conditions: vomiting   Multiple response pattern BL   45708-5    
  J1550C   Problem conditions: dehydrated   Multiple response pattern BL   45696-2    
  J1550D   Problem conditions: internal bleeding   Multiple response pattern BL   45703-6    
  J1550Z   Problem conditions: none of the above   Multiple response pattern BL   54848-7    
  J1700A   Fall history: fall during month before admission   Typical pattern CD   54850-3   1.3.6.1.4.1.12009.10.1.27
  J1700A 0 No   Typical pattern CD   54850-3 LA32-8 1.3.6.1.4.1.12009.10.1.27
  J1700A 1 Yes   Typical pattern CD   54850-3 LA33-6 1.3.6.1.4.1.12009.10.1.27
  J1700A 9 Unable to determine   Typical pattern CD   54850-3 LA11054-6 1.3.6.1.4.1.12009.10.1.27
  J1700B   Fall history: fall 2-6 months before admission   Typical pattern CD   54851-1   1.3.6.1.4.1.12009.10.1.27
  J1700B 0 No   Typical pattern CD   54851-1 LA32-8 1.3.6.1.4.1.12009.10.1.27
  J1700B 1 Yes   Typical pattern CD   54851-1 LA33-6 1.3.6.1.4.1.12009.10.1.27
  J1700B 9 Unable to determine   Typical pattern CD   54851-1 LA11054-6 1.3.6.1.4.1.12009.10.1.27
  J1700C   Fall history: fracture from fall 6 month pre admit   Typical pattern CD   54852-9   1.3.6.1.4.1.12009.10.1.27
  J1700C 0 No   Typical pattern CD   54852-9 LA32-8 1.3.6.1.4.1.12009.10.1.27
  J1700C 1 Yes   Typical pattern CD   54852-9 LA33-6 1.3.6.1.4.1.12009.10.1.27
  J1700C 9 Unable to determine   Typical pattern CD   54852-9 LA11054-6 1.3.6.1.4.1.12009.10.1.27
  J1800   Falls since admit/prior asmt: any falls   Typical pattern CD   54853-7   1.3.6.1.4.1.12009.10.1.62
  J1800 0 No   Typical pattern CD   54853-7 LA32-8 1.3.6.1.4.1.12009.10.1.62
  J1800 1 Yes   Typical pattern CD   54853-7 LA33-6 1.3.6.1.4.1.12009.10.1.62
  J1900A   Falls since admit/prior asmt: no injury   Typical pattern CD   54855-2   1.3.6.1.4.1.12009.10.1.22
  J1900A 0 None   Typical pattern CD   54855-2 LA137-2 1.3.6.1.4.1.12009.10.1.22
  J1900A 1 One   Typical pattern CD   54855-2 LA6306-0 1.3.6.1.4.1.12009.10.1.22
  J1900A 2 Two or more   Typical pattern CD   54855-2 LA11073-6 1.3.6.1.4.1.12009.10.1.22
  J1900B   Falls since admit/prior asmt: injury (not major)   Typical pattern CD   54856-0   1.3.6.1.4.1.12009.10.1.22
  J1900B 0 None   Typical pattern CD   54856-0 LA137-2 1.3.6.1.4.1.12009.10.1.22
  J1900B 1 One   Typical pattern CD   54856-0 LA6306-0 1.3.6.1.4.1.12009.10.1.22
  J1900B 2 Two or more   Typical pattern CD   54856-0 LA11073-6 1.3.6.1.4.1.12009.10.1.22
  J1900C   Falls since admit/prior asmt: major injury   Typical pattern CD   54857-8   1.3.6.1.4.1.12009.10.1.22
  J1900C 0 None   Typical pattern CD   54857-8 LA137-2 1.3.6.1.4.1.12009.10.1.22
  J1900C 1 One   Typical pattern CD   54857-8 LA6306-0 1.3.6.1.4.1.12009.10.1.22
  J1900C 2 Two or more   Typical pattern CD   54857-8 LA11073-6 1.3.6.1.4.1.12009.10.1.22
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
K     Swallowing/Nutritional Status              
  K0100A   Swallow disorder: loss liquids/ solids from mouth   Multiple response pattern BL   54858-6    
  K0100B   Swallow disorder: holds food in mouth/cheeks   Multiple response pattern BL   54859-4    
  K0100C   Swallow disorder: cough/ choke with meals/meds   Multiple response pattern BL   54860-2    
  K0100D   Swallow disorder: difficulty or pain swallowing   Multiple response pattern BL   54861-0    
  K0100Z   Swallow disorder: none of the above   Multiple response pattern BL   54862-8    
  K0200A   Height (in inches)   Other response data type pattern PQ [in_i] 3137-7    
  K0200B   Weight (in pounds)   Other response data type pattern PQ [lb_av] 3141-9    
  K0300   Weight loss   Typical pattern CD   54863-6   1.3.6.1.4.1.12009.10.1.21
  K0300 0 No, or unknown   Typical pattern CD   54863-6 LA11074-4 1.3.6.1.4.1.12009.10.1.21
  K0300 1 Yes, on physician - prescribed weight - loss regimen   Typical pattern CD   54863-6 LA11075-1 1.3.6.1.4.1.12009.10.1.21
  K0300 2 Yes, not on physician - prescribed weight - loss regimen   Typical pattern CD   54863-6 LA11076-9 1.3.6.1.4.1.12009.10.1.21
  K0500A   Nutritional approaches: parenteral /IV feeding   Multiple response pattern BL   54864-4    
  K0500B   Nutritional approaches: feeding tube   Multiple response pattern BL   54865-1    
  K0500C   Nutritional approaches: mechanically altered diet   Multiple response pattern BL   54866-9    
  K0500D   Nutritional approaches: therapeutic diet   Multiple response pattern BL   54867-7    
  K0500Z   Nutritional approaches: none of the above   Multiple response pattern BL   54868-5    
  K0700A   Proportion total calories via parenteral/tube feed   Typical pattern CD   54897-4   1.3.6.1.4.1.12009.10.1.20
  K0700A 1 25% or less   Typical pattern CD   54897-4 LA11077-7 1.3.6.1.4.1.12009.10.1.20
  K0700A 2 26-50%   Typical pattern CD   54897-4 LA11078-5 1.3.6.1.4.1.12009.10.1.20
  K0700A 3 51% or more   Typical pattern CD   54897-4 LA11079-3 1.3.6.1.4.1.12009.10.1.20
  K0700B   Average fluid intake per day by IV or tube   Typical pattern CD   54869-3   1.3.6.1.4.1.12009.10.1.19
  K0700B 1 500 cc/day or less   Typical pattern CD   54869-3 LA11080-1 1.3.6.1.4.1.12009.10.1.19
  K0700B 2 501 cc/day or more   Typical pattern CD   54869-3 LA11081-9 1.3.6.1.4.1.12009.10.1.19
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
L     Oral/Dental Status              
  L0200A   Dental: broken or loosely fitting denture   Multiple response pattern BL   54871-9    
  L0200B   Dental: no natural teeth or tooth fragment(s)   Multiple response pattern BL   54872-7    
  L0200C   Dental: abnormal mouth tissue   Multiple response pattern BL   54873-5    
  L0200D   Dental: cavity or broken natural teeth   Multiple response pattern BL   54874-3    
  L0200E   Dental: inflamed/bleeding gums or loose teeth   Multiple response pattern BL   54875-0    
  L0200F   Dental: pain, discomfort, difficulty chewing   Multiple response pattern BL   54876-8    
  L0200G   Dental: unable to examine   Multiple response pattern BL   58119-9    
  L0200Z   Dental: none of the above   Multiple response pattern BL   54877-6    
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
M     Skin Conditions              
  M0100A   Risk determination: has ulcer, scar, or dressing   Multiple response pattern BL   54878-4    
  M0100B   Risk determination: formal assessment   Multiple response pattern BL   54879-2    
  M0100C   Risk determination: clinical assessment   Multiple response pattern BL   54880-0    
  M0100Z   Risk determination: none of the above   Multiple response pattern BL   54881-8    
  M0150   Is resident at risk of developing pressure ulcer   Typical pattern CD   54882-6   1.3.6.1.4.1.12009.10.1.62
  M0150 0 No   Typical pattern CD   54882-6 LA32-8 1.3.6.1.4.1.12009.10.1.62
  M0150 1 Yes   Typical pattern CD   54882-6 LA33-6 1.3.6.1.4.1.12009.10.1.62
  M0210   Resident has Stage 1 or higher pressure ulcers   Typical pattern CD   58214-8   1.3.6.1.4.1.12009.10.1.62
  M0210 0 No   Typical pattern CD   58214-8 LA32-8 1.3.6.1.4.1.12009.10.1.62
  M0210 1 Yes   Typical pattern CD   58214-8 LA33-6 1.3.6.1.4.1.12009.10.1.62
  M0300A   Stage 1 pressure ulcers: number present   Other response data type pattern INT   54884-2    
  M0300B1   Stage 2 pressure ulcers: number present   Other response data type pattern INT   55124-2    
  M0300B2   Stage 2 pressure ulcers: number at admit/reentry   Other response data type pattern INT   54886-7    
  M0300B3   Stage 2 pressure ulcers: date of oldest   Other response data type pattern TS   58123-1    
  M0300C1   Stage 3 pressure ulcers: number present   Other response data type pattern INT   55125-9    
  M0300C2   Stage 3 pressure ulcers: number at admit/reentry   Other response data type pattern INT   54887-5    
  M0300D1   Stage 4 pressure ulcers: number present   Other response data type pattern INT   55126-7    
  M0300D2   Stage 4 pressure ulcers: number at admit/reentry   Other response data type pattern INT   54890-9    
  M0300E1   Unstaged due to dressing: number present   Other response data type pattern INT   54893-3    
  M0300E2   Unstaged due to dressing: number at admit/reentry   Other response data type pattern INT   54894-1    
  M0300F1   Unstaged slough/eschar: number present   Other response data type pattern INT   54946-9    
  M0300F2   Unstaged slough/eschar: number at admit/reentry   Other response data type pattern INT   54947-7    
  M0300G1   Unstageable - deep tissue: number present   Other response data type pattern INT   54950-1    
  M0300G2   Unstageable - deep tissue: number at admit/reentry   Other response data type pattern INT   54951-9    
  M0610A   Stage 3 or 4 pressure ulcer longest length   Other response data type pattern PQ cm 52728-3    
  M0610B   Stage 3 or 4 pressure ulcer width (same ulcer)   Other response data type pattern PQ cm 52729-1    
  M0610C   Stage 3 or 4 pressure ulcer depth (same ulcer)   Other response data type pattern PQ cm 57228-9    
  M0700   Tissue type for ulcer at most advanced stage   Typical pattern CD   55073-1   1.3.6.1.4.1.12009.10.1.18
  M0700 1 Epithelial Tissue - new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin.   Typical pattern CD   55073-1 LA11082-7 1.3.6.1.4.1.12009.10.1.18
  M0700 2 Granulation Tissue - pink or red tissue with shiny, moist, granular appearance   Typical pattern CD   55073-1 LA11083-5 1.3.6.1.4.1.12009.10.1.18
  M0700 3 Slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous   Typical pattern CD   55073-1 LA11084-3 1.3.6.1.4.1.12009.10.1.18
  M0700 4 Necrotic Tissue (Eschar) - black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin.   Typical pattern CD   55073-1 LA11085-0 1.3.6.1.4.1.12009.10.1.18
  M0800A   Worsened since prior asmt: Stage 2 pressure ulcers   Other response data type pattern INT   54953-5    
  M0800B   Worsened since prior asmt: Stage 3 pressure ulcers   Other response data type pattern INT   54954-3    
  M0800C   Worsened since prior asmt: Stage 4 pressure ulcers   Other response data type pattern INT   54955-0    
  M0900A   Pressure ulcers on prior assessment   Typical pattern CD   54957-6   1.3.6.1.4.1.12009.10.1.62
  M0900A 0 No   Typical pattern CD   54957-6 LA32-8 1.3.6.1.4.1.12009.10.1.62
  M0900A 1 Yes   Typical pattern CD   54957-6 LA33-6 1.3.6.1.4.1.12009.10.1.62
  M0900B   Healed pressure ulcers: Stage 2   Other response data type pattern INT   54958-4    
  M0900C   Healed pressure ulcers: Stage 3   Other response data type pattern INT   54959-2    
  M0900D   Healed pressure ulcers: Stage 4   Other response data type pattern INT   54960-0    
  M1030   Number of venous and arterial ulcers   Other response data type pattern INT   54970-9    
  M1040A   Other skin probs: infection of the foot   Multiple response pattern BL   58228-8    
  M1040B   Other skin probs: diabetic foot ulcer(s)   Multiple response pattern BL   54963-4    
  M1040C   Other skin probs: other open lesion(s) on the foot   Multiple response pattern BL   58125-6    
  M1040D   Other skin probs: lesions not ulcers, rashes, cuts   Multiple response pattern BL   54967-5    
  M1040E   Other skin probs: surgical wound(s)   Multiple response pattern BL   54966-7    
  M1040F   Other skin probs: burn(s) (second or third degree)   Multiple response pattern BL   54968-3    
  M1040Z   Other skin probs: none of the above   Multiple response pattern BL   54969-1    
  M1200A   Skin/ulcer treat: pressure reduce device for chair   Multiple response pattern BL   54972-5    
  M1200B   Skin/ulcer treat: pressure reducing device for bed   Multiple response pattern BL   54973-3    
  M1200C   Skin/ulcer treat: turning/ repositioning   Multiple response pattern BL   54974-1    
  M1200D   Skin/ulcer treat: nutrition/ hydration   Multiple response pattern BL   54975-8    
  M1200E   Skin/ulcer treat: ulcer care   Multiple response pattern BL   54976-6    
  M1200F   Skin/ulcer treat: surgical wound care   Multiple response pattern BL   54977-4    
  M1200G   Skin/ulcer treat: application of dressings   Multiple response pattern BL   54978-2    
  M1200H   Skin/ulcer treat: apply ointments/medications   Multiple response pattern BL   54979-0    
  M1200I   Skin/ulcer treat: apply dressings to feet   Multiple response pattern BL   54980-8    
  M1200Z   Skin/ulcer treat: none of the above   Multiple response pattern BL   54981-6    
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
N     Medications              
  N0300   Number of days injectable medications received   Other response data type pattern PQ d 54982-4    
  N0350A   Insulin: insulin injections   Other response data type pattern PQ d 58127-2    
  N0350B   Insulin: orders for insulin   Other response data type pattern PQ d 58128-0    
  N0400A   Medications: antipsychotic   Multiple response pattern BL   54984-0    
  N0400B   Medications: antianxiety   Multiple response pattern BL   54985-7    
  N0400C   Medications: antidepressant   Multiple response pattern BL   54986-5    
  N0400D   Medications: hypnotic   Multiple response pattern BL   54987-3    
  N0400E   Medications: anticoagulant   Multiple response pattern BL   54988-1    
  N0400F   Medications: antibiotic   Multiple response pattern BL   58129-8    
  N0400G   Medications: diuretic   Multiple response pattern BL   58130-6    
  N0400Z   Medications: none of the above   Multiple response pattern BL   54989-9    
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
O     Special Treatments and Procedures              
  O0100A1   Treatment: chemotherapy - while not resident   Multiple response pattern BL   54992-3    
  O0100A2   Treatment: chemotherapy - while resident   Multiple response pattern BL   54993-1    
  O0100B1   Treatment: radiation - while not resident   Multiple response pattern BL   54994-9    
  O0100B2   Treatment: radiation - while resident   Multiple response pattern BL   54995-6    
  O0100C1   Treatment: oxygen therapy - while not resident   Multiple response pattern BL   54996-4    
  O0100C2   Treatment: oxygen therapy - while resident   Multiple response pattern BL   54997-2    
  O0100D1   Treatment: suctioning - while not resident   Multiple response pattern BL   54998-0    
  O0100D2   Treatment: suctioning - while resident   Multiple response pattern BL   54999-8    
  O0100E1   Treatment: tracheostomy care - while not resident   Multiple response pattern BL   55000-4    
  O0100E2   Treatment: tracheostomy care - while resident   Multiple response pattern BL   55001-2    
  O0100F1   Treatment: vent/respirator - while not resident   Multiple response pattern BL   55002-0    
  O0100F2   Treatment: vent/respirator - while resident   Multiple response pattern BL   55003-8    
  O0100G1   Treatment: BiPAP/CPAP - while not resident   Multiple response pattern BL   55004-6    
  O0100G2   Treatment: BIPAP/CPAP - while resident   Multiple response pattern BL   55005-3    
  O0100H1   Treatment: IV medications - while not resident   Multiple response pattern BL   55006-1    
  O0100H2   Treatment: IV medications - while resident   Multiple response pattern BL   55007-9    
  O0100I1   Treatment: transfusions - while not resident   Multiple response pattern BL   55008-7    
  O0100I2   Treatment: transfusions - while resident   Multiple response pattern BL   55009-5    
  O0100J1   Treatment: dialysis - while not resident   Multiple response pattern BL   55010-3    
  O0100J2   Treatment: dialysis - while resident   Multiple response pattern BL   55011-1    
  O0100K1   Treatment: hospice care - while not resident   Multiple response pattern BL   55012-9    
  O0100K2   Treatment: hospice care - while resident   Multiple response pattern BL   55013-7    
  O0100L2   Treatment: respite care - while resident   Multiple response pattern BL   55015-2    
  O0100M1   Treatment: isolate/quarantine - while not resident   Multiple response pattern BL   55016-0    
  O0100M2   Treatment: isolate/quarantine - while resident   Multiple response pattern BL   55017-8    
  O0100Z1   Treatment: none of above - while not resident   Multiple response pattern BL   59374-9    
  O0100Z2   Treatment: none of above - while resident   Multiple response pattern BL   59373-1    
  O0250A   Was influenza vaccine received   Typical pattern CD   55019-4   1.3.6.1.4.1.12009.10.1.62
  O0250A 0 No   Typical pattern CD   55019-4 LA32-8 1.3.6.1.4.1.12009.10.1.62
  O0250A 1 Yes   Typical pattern CD   55019-4 LA33-6 1.3.6.1.4.1.12009.10.1.62
  O0250B   Date influenza vaccine received.   Other response data type pattern TS   58131-4    
  O0250C   If influenza vaccine not received, state reason   Typical pattern CD   55020-2   1.3.6.1.4.1.12009.10.1.16
  O0250C 1 Resident not in facility during this year's flu season   Typical pattern CD   55020-2 LA12666-6 1.3.6.1.4.1.12009.10.1.16
  O0250C 2 Received outside of this facility   Typical pattern CD   55020-2 LA184-4 1.3.6.1.4.1.12009.10.1.16
  O0250C 3 Not eligible - medical contraindication   Typical pattern CD   55020-2 LA11091-8 1.3.6.1.4.1.12009.10.1.16
  O0250C 4 Offered and declined   Typical pattern CD   55020-2 LA186-9 1.3.6.1.4.1.12009.10.1.16
  O0250C 5 Not offered   Typical pattern CD   55020-2 LA187-7 1.3.6.1.4.1.12009.10.1.16
  O0250C 6 Inability to obtain vaccine due to a declared shortage   Typical pattern CD   55020-2 LA12156-8 1.3.6.1.4.1.12009.10.1.16
  O0250C 9 None of the above   Typical pattern CD   55020-2 LA9-3 1.3.6.1.4.1.12009.10.1.16
  O0300A   Is pneumococcal vaccination up to date   Typical pattern CD   55022-8   1.3.6.1.4.1.12009.10.1.62
  O0300A 0 No   Typical pattern CD   55022-8 LA32-8 1.3.6.1.4.1.12009.10.1.62
  O0300A 1 Yes   Typical pattern CD   55022-8 LA33-6 1.3.6.1.4.1.12009.10.1.62
  O0300B   If pneumococcal vacc not received, state reason   Typical pattern CD   55023-6   1.3.6.1.4.1.12009.10.1.15
  O0300B 1 Not eligible - medical contraindication   Typical pattern CD   55023-6 LA11091-8 1.3.6.1.4.1.12009.10.1.15
  O0300B 2 Offered and declined   Typical pattern CD   55023-6 LA186-9 1.3.6.1.4.1.12009.10.1.15
  O0300B 3 Not offered   Typical pattern CD   55023-6 LA187-7 1.3.6.1.4.1.12009.10.1.15
  O0400A1   Speech-language/audiology: individ minutes   Other response data type pattern PQ min 58218-9    
  O0400A2   Speech-language/audiology: concur minutes   Other response data type pattern PQ min 58133-0    
  O0400A3   Speech-language/audiology: group minutes   Other response data type pattern PQ min 58134-8    
  O0400A4   Speech-language/audiology: number of days   Other response data type pattern PQ d 45760-6    
  O0400A5   Speech-language/audiology: start date   Other response data type pattern TS   55025-1    
  O0400A6   Speech-language/audiology: end date   Other response data type pattern TS   55026-9    
  O0400B1   Occupational therapy: individ minutes   Other response data type pattern PQ min 58219-7    
  O0400B2   Occupational therapy: concur minutes   Other response data type pattern PQ min 58136-3    
  O0400B3   Occupational therapy: group minutes   Other response data type pattern PQ min 58137-1    
  O0400B4   Occupational therapy: number of days   Other response data type pattern PQ d 45762-2    
  O0400B5   Occupational therapy: start date   Other response data type pattern TS   55027-7    
  O0400B6   Occupational therapy: end date   Other response data type pattern TS   55028-5    
  O0400C1   Physical therapy: individ minutes   Other response data type pattern PQ min 58220-5    
  O0400C2   Physical therapy: concur minutes   Other response data type pattern PQ min 58139-7    
  O0400C3   Physical therapy: group minutes   Other response data type pattern PQ min 58140-5    
  O0400C4   Physical therapy: number of days   Other response data type pattern PQ d 45764-8    
  O0400C5   Physical therapy: start date   Other response data type pattern TS   55029-3    
  O0400C6   Physical therapy: end date   Other response data type pattern TS   55030-1    
  O0400D1   Respiratory therapy: number of minutes   Other response data type pattern PQ min 45767-1    
  O0400D2   Respiratory therapy: number of days   Other response data type pattern PQ d 45766-3    
  O0400E1   Psychological therapy: number of minutes   Other response data type pattern PQ min 45852-1    
  O0400E2   Psychological therapy: number of days   Other response data type pattern PQ d 45768-9    
  O0400F1   Recreational therapy: number of minutes   Other response data type pattern PQ min 55035-0    
  O0400F2   Recreational therapy: number of days   Other response data type pattern PQ d 55036-8    
  O0450A   Has therapy resumed NEW RUGs ITEMS            
  O0450B   Therapy resumption date NEW RUGs ITEMS            
  O0500A   Range of motion (passive): number of days   Other response data type pattern PQ d 45859-6    
  O0500B   Range of motion (active): number of days   Other response data type pattern PQ d 45860-4    
  O0500C   Splint or brace assistance: number of days   Other response data type pattern PQ d 45861-2    
  O0500D   Bed mobility training: number of days   Other response data type pattern PQ d 45862-0    
  O0500E   Transfer training: number of days   Other response data type pattern PQ d 45863-8    
  O0500F   Walking training: number of days   Other response data type pattern PQ d 45864-6    
  O0500G   Dressing and/or grooming training: number of days   Other response data type pattern PQ d 45865-3    
  O0500H   Eating and/or swallowing training: number of days   Other response data type pattern PQ d 45866-1    
  O0500I   Amputation/prosthesis training: number of days   Other response data type pattern PQ d 45867-9    
  O0500J   Communication training: number of days   Other response data type pattern PQ d 45868-7    
  O0600   Physician examinations: number of days   Other response data type pattern PQ d 55040-0    
  O0700   Physician orders: number of days   Other response data type pattern PQ d 55041-8    
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
P     Restraints              
  P0100A   Restraints used in bed: bed rail   Typical pattern CD   55044-2   1.3.6.1.4.1.12009.10.1.63
  P0100A 0 Not used   Typical pattern CD   55044-2 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100A 1 Used less than daily   Typical pattern CD   55044-2 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100A 2 Used daily   Typical pattern CD   55044-2 LA159-6 1.3.6.1.4.1.12009.10.1.63
  P0100B   Restraints used in bed: trunk restraint   Typical pattern CD   55045-9   1.3.6.1.4.1.12009.10.1.63
  P0100B 0 Not used   Typical pattern CD   55045-9 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100B 1 Used less than daily   Typical pattern CD   55045-9 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100B 2 Used daily   Typical pattern CD   55045-9 LA159-6 1.3.6.1.4.1.12009.10.1.63
  P0100C   Restraints used in bed: limb restraint   Typical pattern CD   55046-7   1.3.6.1.4.1.12009.10.1.63
  P0100C 0 Not used   Typical pattern CD   55046-7 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100C 1 Used less than daily   Typical pattern CD   55046-7 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100C 2 Used daily   Typical pattern CD   55046-7 LA159-6 1.3.6.1.4.1.12009.10.1.63
  P0100D   Restraints used in bed: other   Typical pattern CD   55047-5   1.3.6.1.4.1.12009.10.1.63
  P0100D 0 Not used   Typical pattern CD   55047-5 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100D 1 Used less than daily   Typical pattern CD   55047-5 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100D 2 Used daily   Typical pattern CD   55047-5 LA159-6 1.3.6.1.4.1.12009.10.1.63
  P0100E   Restraints in chair/out of bed: trunk restraint   Typical pattern CD   55048-3   1.3.6.1.4.1.12009.10.1.63
  P0100E 0 Not used   Typical pattern CD   55048-3 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100E 1 Used less than daily   Typical pattern CD   55048-3 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100E 2 Used daily   Typical pattern CD   55048-3 LA159-6 1.3.6.1.4.1.12009.10.1.63
  P0100F   Restraints in chair/out of bed: limb restraint   Typical pattern CD   55049-1   1.3.6.1.4.1.12009.10.1.63
  P0100F 0 Not used   Typical pattern CD   55049-1 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100F 1 Used less than daily   Typical pattern CD   55049-1 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100F 2 Used daily   Typical pattern CD   55049-1 LA159-6 1.3.6.1.4.1.12009.10.1.63
  P0100G   Restraints in chair/out of bed: chair stops rising   Typical pattern CD   55050-9   1.3.6.1.4.1.12009.10.1.63
  P0100G 0 Not used   Typical pattern CD   55050-9 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100G 1 Used less than daily   Typical pattern CD   55050-9 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100G 2 Used daily   Typical pattern CD   55050-9 LA159-6 1.3.6.1.4.1.12009.10.1.63
  P0100H   Restraints in chair/out of bed: other   Typical pattern CD   55051-7   1.3.6.1.4.1.12009.10.1.63
  P0100H 0 Not used   Typical pattern CD   55051-7 LA157-0 1.3.6.1.4.1.12009.10.1.63
  P0100H 1 Used less than daily   Typical pattern CD   55051-7 LA158-8 1.3.6.1.4.1.12009.10.1.63
  P0100H 2 Used daily   Typical pattern CD   55051-7 LA159-6 1.3.6.1.4.1.12009.10.1.63
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
Q     Participation in Assessment and Goal Setting              
  Q0100A   Resident participated in assessment   Typical pattern CD   55054-1   1.3.6.1.4.1.12009.10.1.62
  Q0100A 0 No   Typical pattern CD   55054-1 LA32-8 1.3.6.1.4.1.12009.10.1.62
  Q0100A 1 Yes   Typical pattern CD   55054-1 LA33-6 1.3.6.1.4.1.12009.10.1.62
  Q0100B   Family/signif other participated in assessment   Typical pattern CD   55074-9   1.3.6.1.4.1.12009.10.1.14
  Q0100B 0 No   Typical pattern CD   55074-9 LA32-8 1.3.6.1.4.1.12009.10.1.14
  Q0100B 1 Yes   Typical pattern CD   55074-9 LA33-6 1.3.6.1.4.1.12009.10.1.14
  Q0100B 9 No family or significant other   Typical pattern CD   55074-9 LA11104-9 1.3.6.1.4.1.12009.10.1.14
  Q0100C   Guardian/legal rep participated in assessment   Typical pattern CD   58221-3   1.3.6.1.4.1.12009.10.1.135
  Q0100C 0 No   Typical pattern CD   58221-3 LA32-8 1.3.6.1.4.1.12009.10.1.135
  Q0100C 1 Yes   Typical pattern CD   58221-3 LA33-6 1.3.6.1.4.1.12009.10.1.135
  Q0100C 9 No guardian or legally authorized representative   Typical pattern CD   58221-3 LA12662-5 1.3.6.1.4.1.12009.10.1.135
  Q0300A   Resident's overall goal   Typical pattern CD   55057-4   1.3.6.1.4.1.12009.10.1.12
  Q0300A 1 Expects to be discharged to the community   Typical pattern CD   55057-4 LA11108-0 1.3.6.1.4.1.12009.10.1.12
  Q0300A 2 Expects to remain in this facility   Typical pattern CD   55057-4 LA11109-8 1.3.6.1.4.1.12009.10.1.12
  Q0300A 3 Expects to be discharged to another facility/institution   Typical pattern CD   55057-4 LA11110-6 1.3.6.1.4.1.12009.10.1.12
  Q0300A 9 Unknown or uncertain   Typical pattern CD   55057-4 LA11107-2 1.3.6.1.4.1.12009.10.1.12
  Q0300B   Information source for resident's goal   Typical pattern CD   55058-2   1.3.6.1.4.1.12009.10.1.73
  Q0300B 1 Resident   Typical pattern CD   55058-2 LA11019-9 1.3.6.1.4.1.12009.10.1.73
  Q0300B 2 If not resident, then family or significant other   Typical pattern CD   55058-2 LA11116-3 1.3.6.1.4.1.12009.10.1.73
  Q0300B 3 If not resident, family or significant other, then guardian or legally authorized representative   Typical pattern CD   55058-2 LA12652-6 1.3.6.1.4.1.12009.10.1.73
  Q0300B 9 None of the above   Typical pattern CD   55058-2 Q0300B-9 1.3.6.1.4.1.12009.10.1.11
  Q0400A   Active discharge plan for return to community   Typical pattern CD   58146-2   1.3.6.1.4.1.12009.10.1.62
  Q0400A 0 No   Typical pattern CD   58146-2 LA32-8 1.3.6.1.4.1.12009.10.1.62
  Q0400A 1 Yes   Typical pattern CD   58146-2 LA33-6 1.3.6.1.4.1.12009.10.1.62
  Q0400B   Determination regarding discharge to community   Typical pattern CD   58147-0   1.3.6.1.4.1.12009.10.1.74
  Q0400B 0 Determination not made   Typical pattern CD   58147-0 LA12653-4 1.3.6.1.4.1.12009.10.1.74
  Q0400B 1 Discharge to community determined to be feasible   Typical pattern CD   58147-0 LA12654-2 1.3.6.1.4.1.12009.10.1.74
  Q0400B 2 Discharge to community determined to be not feasible   Typical pattern CD   58147-0 LA12655-9 1.3.6.1.4.1.12009.10.1.74
  Q0500A   Resident been asked about return to community   Typical pattern CD   58148-8   1.3.6.1.4.1.12009.10.1.75
  Q0500A 0 No   Typical pattern CD   58148-8 LA32-8 1.3.6.1.4.1.12009.10.1.75
  Q0500A 1 Yes--previous response was "no"   Typical pattern CD   58148-8 LA12656-7 1.3.6.1.4.1.12009.10.1.75
  Q0500A 2 Yes--previous response was "yes"   Typical pattern CD   58148-8 LA12657-5 1.3.6.1.4.1.12009.10.1.75
  Q0500A 3 Yes--previous response was "unknown"   Typical pattern CD   58148-8 LA12658-3 1.3.6.1.4.1.12009.10.1.75
  Q0500B   Do you want to talk about returning to community   Typical pattern CD   58149-6   1.3.6.1.4.1.12009.10.1.13
  Q0500B 0 No   Typical pattern CD   58149-6 LA32-8 1.3.6.1.4.1.12009.10.1.13
  Q0500B 1 Yes   Typical pattern CD   58149-6 LA33-6 1.3.6.1.4.1.12009.10.1.13
  Q0500B 9 Unknown or uncertain   Typical pattern CD   58149-6 LA11107-2 1.3.6.1.4.1.12009.10.1.13
  Q0600   Referral been made to local contact agency   Typical pattern CD   58150-4   1.3.6.1.4.1.12009.10.1.77
  Q0600 0 No--determination has been made by the resident and the care planning team that contact is not required   Typical pattern CD   58150-4 LA12659-1 1.3.6.1.4.1.12009.10.1.77
  Q0600 1 No--referral not made   Typical pattern CD   58150-4 LA12660-9 1.3.6.1.4.1.12009.10.1.77
  Q0600 2 Yes   Typical pattern CD   58150-4 LA33-6 1.3.6.1.4.1.12009.10.1.77
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
T     Therapy Supplement for Medicare PPS              
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
V                    
  V0100A   Prior OBRA reason for assessment   Typical pattern CD   54583-0   1.3.6.1.4.1.12009.10.1.60
  V0100A 1 Admission assessment (required by day 14)   Typical pattern CD   54583-0 LA10-4 1.3.6.1.4.1.12009.10.1.60
  V0100A 2 Quarterly review assessment   Typical pattern CD   54583-0 LA15-3 1.3.6.1.4.1.12009.10.1.60
  V0100A 3 Annual assessment   Typical pattern CD   54583-0 LA12-0 1.3.6.1.4.1.12009.10.1.60
  V0100A 4 Significant change in status assessment   Typical pattern CD   54583-0 LA13-8 1.3.6.1.4.1.12009.10.1.60
  V0100A 5 Significant correction to prior comprehensive assessment   Typical pattern CD   54583-0 LA10888-8 1.3.6.1.4.1.12009.10.1.60
  V0100A 6 Significant correction to prior quarterly assessment   Typical pattern CD   54583-0 LA10889-6 1.3.6.1.4.1.12009.10.1.60
  V0100A 99 Not OBRA required assessment/tracking   Typical pattern CD   54583-0 LA10893-8 1.3.6.1.4.1.12009.10.1.60
  V0100B   Prior PPS reason for assessment   Typical pattern CD   54584-8   1.3.6.1.4.1.12009.10.1.59
  V0100B 1 5-day scheduled assessment   Typical pattern CD   54584-8 LA10894-6 1.3.6.1.4.1.12009.10.1.59
  V0100B 2 14-day scheduled assessment   Typical pattern CD   54584-8 LA10895-3 1.3.6.1.4.1.12009.10.1.59
  V0100B 3 30-day scheduled assessment   Typical pattern CD   54584-8 LA10896-1 1.3.6.1.4.1.12009.10.1.59
  V0100B 4 60-day scheduled assessment   Typical pattern CD   54584-8 LA10897-9 1.3.6.1.4.1.12009.10.1.59
  V0100B 5 90-day scheduled assessment   Typical pattern CD   54584-8 LA10898-7 1.3.6.1.4.1.12009.10.1.59
  V0100B 6 Readmission/return assessment   Typical pattern CD   54584-8 LA10899-5 1.3.6.1.4.1.12009.10.1.59
  V0100B 7 Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)   Typical pattern CD   54584-8 LA10900-1 1.3.6.1.4.1.12009.10.1.59
  V0100B 99 Not PPS assessment   Typical pattern CD   54584-8 LA10903-5 1.3.6.1.4.1.12009.10.1.59
  V0100C   Prior assessment reference date   Other response data type pattern TS   58151-2    
  V0100D   Prior assessment BIMS summary score   Other response data type pattern INT   58152-0    
  V0100E   Prior asmt PHQ res: total mood severity score   Other response data type pattern INT   58153-8    
  V0100F   Prior asmt PHQ staff: total mood score   Other response data type pattern INT   58153-8    
  V0200A01A   CAA-Delirium: triggered   Multiple response pattern BL   58157-9    
  V0200A01B   CAA-Delirium: plan   Multiple response pattern BL   58158-7    
  V0200A02A   CAA-Cognitive loss/dementia: triggered   Multiple response pattern BL   58159-5    
  V0200A02B   CAA-Cognitive loss/dementia: plan   Multiple response pattern BL   58160-3    
  V0200A03A   CAA-Visual function: triggered   Multiple response pattern BL   58226-2    
  V0200A03B   CAA-Visual function: plan   Multiple response pattern BL   58225-4    
  V0200A04A   CAA-Communication: triggered   Multiple response pattern BL   58161-1    
  V0200A04B   CAA-Communication: plan   Multiple response pattern BL   58162-9    
  V0200A05A   CAA-ADL functional/rehab potential: triggered   Multiple response pattern BL   58163-7    
  V0200A05B   CAA-ADL functional/rehab potential: plan   Multiple response pattern BL   58164-5    
  V0200A06A   CAA-Urinary incont/indwell catheter: triggered   Multiple response pattern BL   58165-2    
  V0200A06B   CAA-Urinary incont/indwell catheter: plan   Multiple response pattern BL   58166-0    
  V0200A07A   CAA-Psychosocial well-being: triggered   Multiple response pattern BL   58167-8    
  V0200A07B   CAA-Psychosocial well-being: plan   Multiple response pattern BL   58168-6    
  V0200A08A   CAA-Mood state: triggered   Multiple response pattern BL   58169-4    
  V0200A08B   CAA-Mood state: plan   Multiple response pattern BL   58170-2    
  V0200A09A   CAA-Behavioral symptoms: triggered   Multiple response pattern BL   58171-0    
  V0200A09B   CAA-Behavioral symptoms: plan   Multiple response pattern BL   58172-8    
  V0200A10A   CAA-Activities: triggered   Multiple response pattern BL   58173-6    
  V0200A10B   CAA-Activities: plan   Multiple response pattern BL   58174-4    
  V0200A11A   CAA-Falls: triggered   Multiple response pattern BL   58175-1    
  V0200A11B   CAA-Falls: plan   Multiple response pattern BL   58176-9    
  V0200A12A   CAA-Nutritional status: triggered   Multiple response pattern BL   58177-7    
  V0200A12B   CAA-Nutritional status: plan   Multiple response pattern BL   58178-5    
  V0200A13A   CAA-Feeding tubes: triggered   Multiple response pattern BL   8179-3    
  V0200A13B   CAA-Feeding tubes: plan   Multiple response pattern BL   58180-1    
  V0200A14A   CAA-Dehydration/fluid maintenance: triggered   Multiple response pattern BL   58181-9    
  V0200A14B   CAA-Dehydration/fluid maintenance: plan   Multiple response pattern BL   58182-7    
  V0200A15A   CAA-Dental care: triggered   Multiple response pattern BL   58183-5    
  V0200A15B   CAA-Dental care: plan   Multiple response pattern BL   58184-3    
  V0200A16A   CAA-Pressure ulcer: triggered   Multiple response pattern BL   58185-0    
  V0200A16B   CAA-Pressure ulcer: plan   Multiple response pattern BL   58186-8    
  V0200A17A   CAA-Psychotropic drug use: triggered   Multiple response pattern BL   58187-6    
  V0200A17B   CAA-Psychotropic drug use: plan   Multiple response pattern BL   58188-4    
  V0200A18A   CAA-Physical restraints: triggered   Multiple response pattern BL   58189-2    
  V0200A18B   CAA-Physical restraints: plan   Multiple response pattern BL   58190-0    
  V0200A19A   CAA-Pain: triggered   Multiple response pattern BL   58191-8    
  V0200A19B   CAA-Pain: plan   Multiple response pattern BL   58192-6    
  V0200A20A   CAA-Return to community referral: triggered   Multiple response pattern BL   58193-4    
  V0200A20B   CAA-Return to community referral: plan   Multiple response pattern BL   58194-2    
  V0200B2   CAA-Assessment process signature date   Other response data type pattern TS        
  V0200C2   CAA-Care planning signature date   Other response data type pattern TS        
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
X                    
  X0100   Correction: type of transaction   Typical pattern CD   58198-3   1.3.6.1.4.1.12009.10.1.159
  X0100 1 Add new record   Typical pattern CD   58198-3 LA12663-3 1.3.6.1.4.1.12009.10.1.159
  X0100 2 Modify existing record   Typical pattern CD   58198-3 LA12664-1 1.3.6.1.4.1.12009.10.1.159
  X0100 3 Inactivate existing record   Typical pattern CD   58198-3 LA12665-8 1.3.6.1.4.1.12009.10.1.159
  X0150   Correction: type of provider   Typical pattern CD   54582-2   1.3.6.1.4.1.12009.10.1.61
  X0150 1 Nursing home (SNF/NF)   Typical pattern CD   54582-2 LA10882-1 1.3.6.1.4.1.12009.10.1.61
  X0150 2 Swing bed   Typical pattern CD   54582-2 LA10883-9 1.3.6.1.4.1.12009.10.1.61
  X0200A   Correction: resident first name   Other Response Data Type Pattern ED   54503-8    
  X0200C   Correction: resident last name   Other Response Data Type Pattern ED   54503-8    
  X0300   Correction: resident gender   Typical pattern CD   46098-0   2.16.840.1.113883.5.1
  X0300 1 Male   Typical pattern CD   46098-0 LA2-8  
  X0300 2 Female   Typical pattern CD   46098-0 LA3-6  
  X0400   Correction: resident birth date   Other response data type pattern TS   21112-8    
  X0500   Correction: resident social security number   Other Response Data Type Pattern ED   45966-9    
  X0600A   Correction: OBRA reason for assessment   Typical pattern CD   54583-0   1.3.6.1.4.1.12009.10.1.60
  X0600A 1 Admission assessment (required by day 14)   Typical pattern CD   54583-0 LA10-4 1.3.6.1.4.1.12009.10.1.60
  X0600A 2 Quarterly review assessment   Typical pattern CD   54583-0 LA15-3 1.3.6.1.4.1.12009.10.1.60
  X0600A 3 Annual assessment   Typical pattern CD   54583-0 LA12-0 1.3.6.1.4.1.12009.10.1.60
  X0600A 4 Significant change in status assessment   Typical pattern CD   54583-0 LA13-8 1.3.6.1.4.1.12009.10.1.60
  X0600A 5 Significant correction to prior comprehensive assessment   Typical pattern CD   54583-0 LA10888-8 1.3.6.1.4.1.12009.10.1.60
  X0600A 6 Significant correction to prior quarterly assessment   Typical pattern CD   54583-0 LA10889-6 1.3.6.1.4.1.12009.10.1.60
  X0600A 99 Not OBRA required assessment/ tracking   Typical pattern CD   54583-0 LA10893-8 1.3.6.1.4.1.12009.10.1.60
  X0600B   Correction: PPS reason for assessment   Typical pattern CD   54584-8   1.3.6.1.4.1.12009.10.1.59
  X0600B 1 5-day scheduled assessment   Typical pattern CD   54584-8 LA10894-6 1.3.6.1.4.1.12009.10.1.59
  X0600B 2 14-day scheduled assessment   Typical pattern CD   54584-8 LA10895-3 1.3.6.1.4.1.12009.10.1.59
  X0600B 3 30-day scheduled assessment   Typical pattern CD   54584-8 LA10896-1 1.3.6.1.4.1.12009.10.1.59
  X0600B 4 60-day scheduled assessment   Typical pattern CD   54584-8 LA10897-9 1.3.6.1.4.1.12009.10.1.59
  X0600B 5 90-day scheduled assessment   Typical pattern CD   54584-8 LA10898-7 1.3.6.1.4.1.12009.10.1.59
  X0600B 6 Readmission/return assessment   Typical pattern CD   54584-8 LA10899-5 1.3.6.1.4.1.12009.10.1.59
  X0600B 7 Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)   Typical pattern CD   54584-8 LA10900-1 1.3.6.1.4.1.12009.10.1.59
  X0600B 99 Not PPS assessment   Typical pattern CD   54584-8 LA10903-5 1.3.6.1.4.1.12009.10.1.59
  X0600C   Correction: OMRA assessment   Typical pattern CD   54585-5   1.3.6.1.4.1.12009.10.1.65
  X0600C 0 No   Typical pattern CD   54585-5 LA32-8 1.3.6.1.4.1.12009.10.1.65
  X0600C 1 Start of therapy assessment   Typical pattern CD   54585-5 LA12624-5 1.3.6.1.4.1.12009.10.1.65
  X0600C 2 End of therapy assessment   Typical pattern CD   54585-5 LA12625-2 1.3.6.1.4.1.12009.10.1.65
  X0600C 3 Both Start and End of therapy assessment   Typical pattern CD   54585-5 LA12626-0 1.3.6.1.4.1.12009.10.1.65
  X0600D   Correction: Swing bed clinical change asmt   Typical pattern CD   58107-4   1.3.6.1.4.1.12009.10.1.62
  X0600D 0 No   Typical pattern CD   58107-4 LA32-8 1.3.6.1.4.1.12009.10.1.62
  X0600D 1 Yes   Typical pattern CD   58107-4 LA33-6 1.3.6.1.4.1.12009.10.1.62
  X0600F   Correction: entry/discharge reporting   Typical pattern CD   58108-2   1.3.6.1.4.1.12009.10.1.66
  X0600F 1 Entry record   Typical pattern CD   58108-2 LA12627-8 1.3.6.1.4.1.12009.10.1.66
  X0600F 10 Discharge assessment - return not anticipated   Typical pattern CD   58108-2 LA12628-6 1.3.6.1.4.1.12009.10.1.66
  X0600F 11 Discharge assessment - return anticipated   Typical pattern CD   58108-2 LA12629-4 1.3.6.1.4.1.12009.10.1.66
  X0600F 12 Death in facility record   Typical pattern CD   58108-2 LA12630-2 1.3.6.1.4.1.12009.10.1.66
  X0600F 99 Not entry/discharge   Typical pattern CD   58108-2 LA12631-0 1.3.6.1.4.1.12009.10.1.66
  X0700A   Correction: assessment reference date   Other response data type pattern TS   54593-9    
  X0700B   Correction: discharge date   Other response data type pattern TS   52525-3    
  X0700C   Correction: entry date   Other response data type pattern TS   50786-3    
  X0800   Correction: correction number   Other response data type pattern INT   58200-7    
  X0900A   Correction: modif reasons - transcription error   Multiple response pattern BL   58201-5    
  X0900B   Correction: modif reasons - data entry error   Multiple response pattern BL   58202-3    
  X0900C   Correction: modif reasons - software error   Multiple response pattern BL   58203-1    
  X0900D   Correction: modif reasons - item coding error   Multiple response pattern BL   58227-0    
  X0900Z   Correction: modif reasons - other error   Multiple response pattern BL   58204-9    
  X1050A   Correction: inact reasons - event did not occur   Multiple response pattern BL   58207-2    
  X1050Z   Correction: inact reasons - other reason   Multiple response pattern BL   58208-0    
  X1100A   Correction: attestor first name   Other response data type pattern ED        
  X1100B   Correction: attestor last name   Other response data type pattern ED        
  X1100E   Correction: attestation date   Other response data type pattern TS        
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
Z     Assessment Administration              
  Z0100A   Medicare Part A: HIPPS code   Other response data type pattern ED   55065-7    
  Z0100B   Medicare Part A: RUG version code   Other response data type pattern ED   55066-5    
  Z0100C   Medicare Part A: Medicare short stay asmt   Typical pattern CD   58421-9   1.3.6.1.4.1.12009.10.1.62
  Z0100C 0 No   Typical pattern CD   58421-9 LA32-8 1.3.6.1.4.1.12009.10.1.62
  Z0100C 1 Yes   Typical pattern CD   58421-9 LA33-6 1.3.6.1.4.1.12009.10.1.62
  Z0150A   Medicare Part A: non-therapy HIPPS code   Other response data type pattern ED   58210-6    
  Z0150B   Medicare Part A: non-therapy RUG version code   Other response data type pattern ED   58211-4    
  Z0200A   State case mix: RUG group   Other response data type pattern ED   55068-1    
  Z0200B   State case mix: RUG version code   Other response data type pattern ED   55069-9    
  Z0250A   State case mix: Alternate RUG group   Other response data type pattern ED   58212-2    
  Z0250B   State case mix: Alternate RUG version code   Other response data type pattern ED   58213-0    
  Z0500B   Date RN signed assessment as complete See CDA X-Path Mapping
Table 27
Implementation Guide for CDA R2 - CDA Framework/ MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
           
Section CMS Question ID Answer CMS Description
Light Blue Shading Indicates Start of New Question per CMS Data Dictionary
General Guidance Pattern Data Type Units LOINC Question Code LOINC Answer Code LOINC Answer Set OID
OTHER                    
  FAC_ID   Assigned facility/provider submission ID   Other response data type pattern ED   55077-2    
  SFTWR_PROD_ NAME   Software product name              
  SFTWR_PROD_ NAME   Software product name              
  SFTWR_PROD_ VRSN_CD   Software product version code              
  SFTWR_PROD_ VRSN_CD   Software product version code              
  SFTWR_VNDR_ EMAIL_ADR   Software vendor email address              
  SFTWR_VNDR_ EMAIL_ADR   Software vendor email address              
  SFTWR_VNDR_ID   Software vendor federal employer tax ID              
  SFTWR_VNDR_ID   Software vendor federal employer tax ID              
  SFTWR_VNDR_ NAME   Software vendor company name              
  SFTWR_VNDR_ NAME   Software vendor company name              
  SPEC_VRSN_CD   Specifications version code              
  SPEC_VRSN_CD   Specifications version code              
  ITM_SBST_CD   Item subset code              
  ITM_SBST_CD NCN Nursing home comprehensive assessment              
  ITM_SBST_CD NCP Nursing home comprehensive assessment coupled with PPS assessment              
  ITM_SBST_CD NDE Nursing home discharge coupled with EMCA              
  ITM_SBST_CD NDN Nursing home discharge              
  ITM_SBST_CD NEN Nursing home entry              
  ITM_SBST_CD NNE Nursing home EMCA              
  ITM_SBST_CD NNN Nursing home not OMBRA and not PPS assessment              
  ITM_SBST_CD NNP Nursing home PPS assessment              
  ITM_SBST_CD NQN Nursing home quarterly assessment              
  ITM_SBST_CD NQP Nursing home quarterly assessment coupled with PPS assessment              
  ITM_SBST_CD SDE Swing bed discharge coupled with EMCA              
  ITM_SBST_CD SDN Swing bed discharge              
  ITM_SBST_CD SEN Swing bed entry              
  ITM_SBST_CD SNE Swing bed EMCA              
  ITM_SBST_CD SNN Swing bed not a PPS assessment              
  ITM_SBST_CD SNP Swing bed PPS assessment              
  ITM_SBST_CD SNS Swing bed clinical change assessment              
  ITM_SBST_CD XXX Inactivation transaction              
  PRODN_TEST_CD   Production/test indicator              
  PRODN_TEST_CD P Product submission              
  PRODN_TEST_CD T Test submission              

 

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